Outcomes of Dual Mobility Acetabular Cups in Total Hip Arthroplasty Patients
Steven F. Harwin, MD, Chief of Advanced Technology of Total Hip and Knee Arthoplasty, Mount Sinai West, New York, New York, Nipun Sodhi, MD, Research Fellow, Joseph Ehiorobo, MD, Research Fellow, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Anton Khlopas, MD, Resident, PGY – 1, Assem A. Sultan, MD, Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Background: Instability can account for over 20% of all revision total hip arthroplasties (THAs). Although a number of surgical techniques have been developed to limit the number of dislocations, prevention still remains a challenge. More recently, dual mobility (DM) cups have been developed to potentially target this problem. Although this implant design has been shown to have a number of potential advantages in the revision setting, there is limited data in the literature on the use of modular dual mobility (MDM) implants for primary THAs. Therefore, the purpose of this study was to evaluate cup survivorships, patient satisfaction outcomes, and complications of this device used for primary THA.
Materials and Methods: A total of 143 consecutive hips (131 patients) who underwent primary THA using DM prostheses by a high-volume academic surgeon were longitudinally followed up for a minimum of five years (mean: 6 years, 11 months; range, 6 years 3 months to 7 years 5 months). There were 77 women (54%) and 66 men (44%) who had a mean age 65 years (range, 34 to 90 years; SD, 11 years), and the mean body mass index (BMI) was 32 kg/m2 (range, 22 to 52; SD, 8 kg/m2). Patient demographics, (gender, BMI), as well as clinical outcomes were analyzed. Kaplan-Meier analysis was performed to determine aseptic, septic, and all-cause cup survivorship. Additionally, clinical outcomes based on Harris Hip Scores (HHS) and other modalities, as well as complications, were tabulated. Institutional review board (IRB) approval was received prior to initiating this study.
Results: Septic survivorship was found to be 99.3% (95% CI: 0.98 to 1.0), while all-cause survivorship was 98.6% (95% CI: 0.97 to 1.0). There were a total of two revision surgeries; however, these were not related to the MDM cup. Specifically, one patient had femoral stem loosening, while another patient had a late deep infection treated with a two-stage procedure. At most recent follow up, both patients were progressing well and had HHS scores of 85 and 92 points. The mean total HHS score was 95 points (range, 64 to 100) at most recent follow up. Other complications affecting patient outcomes included two patients who presented with concerns for deep vein thrombi, which were both medically managed, as well as one patient who had a non-fatal pulmonary embolism, which was also medically managed. The final HHS scores for these three patients were 83, 100, and 96 points.
Conclusion: DM cups were designed with the intent of reducing hip instability. Most studies on these cups have reported on revision THA, where the problem of instability may be more paramount; however, fewer studies have reported on the use of this cup for primary THA. The findings from this study indicate excellent survivorship and overall clinical and patient satisfaction results using this construct. These five-year results are very encouraging and hopefully will portend excellent further survivorship with longer follow up.
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Lateral Unicompartmental Knee Arthroplasty Utilizing a Modified Surgical Technique and Specifically Adapted Fixed-Bearing Implant
Nicholas J Greco, MD, Orthopaedic Surgeon, Joint Implant Surgeons, Inc., New Albany, Ohio, Gary J. E. Cook, BS, Research Intern, Joint Implant Surgeons, Inc., New Albany, Ohio, Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, The Ohio State University Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Joanne B. Adams, BFA, CMI, Research Director, Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, President, White Fence Surgical Suites, LLC, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio
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Background: Treatment of isolated lateral compartment arthritic disease with partial knee arthroplasty remains underutilized in comparison to medial unicompartmental arthroplasty. This study examines the survival and outcome of lateral unicompartmental arthroplasty utilizing the first implant specifically developed for the lateral compartment.
Materials and Methods: A retrospective review was performed to detect lateral unicompartmental arthroplasty procedures performed in our practice between January 2013 and May 2016. Patients indicated for surgery met specific preoperative clinical and radiographic criteria confirming lateral compartment arthritic disease with a correctable deformity, intact full-thickness medial cartilage, competent anterior cruciate ligament, and minimal disease in the patellofemoral compartment. A single implant design was used in all cases which consisted of a fixed-bearing tibial component specifically adapted to lateral compartment anatomy. Unicompartmental arthroplasty surgical technique was adjusted to attempt to recreate lateral compartment kinematics.
Results: Fifty-two consecutive patients (56 knees) with lateral unicompartmental arthroplasty procedures meeting minimum two-year follow up were included in the study. Thirty-nine patients were female, and 93% of cases were performed for treatment of osteoarthritis. At a mean follow up of nearly three years, Knee Society clinical and functional scores improved postoperatively by a mean difference of 41 and 21, respectively. There were two reoperations, one medial unicompartmental arthroplasty for osteoarthritis progression and a superficial debridement for a non-healing wound. Thus, failure of lateral unicondylar knee arthroplasty (UKA) was less than 2% in this study. There were no other component revisions, radiographic evidence of loosening, or clinical failures.
Conclusions: At early follow up, lateral unicompartmental arthroplasty using a modified surgical technique and an implant specifically designed for the lateral compartment is a reliable treatment for isolated lateral femorotibial arthritis when meeting defined indications.
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Preoperative Functional Status Predicts Increased Morbidity Following Total Knee Arthroplasty
Gannon Curtis, MD, Resident Physician, Aws Hammad, MD, Resident Physician, Hussein F. Darwiche, MD, Bryan E. Little, MD, Orthopaedic Surgeon, Detroit Medical Center, Detroit, Michigan, Hiba K. Anis, MD, Research Fellow, Cleveland Clinic, Cleveland, Ohio, Nipun Sodhi, MD, Research Fellow, Joseph O. Ehiorobo, MD, Research Fellow, Michael A. Mont, MD, Director of Joint Arthroplasty, Lenox Hill Hospital, Northwell Health, New York, New York, Carlos A. Higuera, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Introduction: Dependent functional status (DEP) has been associated with higher postoperative adverse events and mortality compared to patients with independent functional status (IND). However, the association between preoperative functional status and perioperative outcomes after primary TKA has not been well reported. Therefore, the purpose of this study was to evaluate this association. Specifically, we asked: 1) does preoperative functional status impact perioperative outcomes following primary TKA, and 2) is DEP functional status prior to primary TKA an independent risk factor for 30-day complications?
Materials and Methods: Primary TKAs were identified from 2012 to 2016 in the National Surgical Quality Improvement Program (NSQIP) database. A total of 188,172 cases were included. Preoperative functional status was determined by the ability to perform ADLs. Patients who could perform all ADLs were classified as independent functional status (IND; n=186,066), and patients who required assistance with ADLs were classified as dependent functional status (DEP; n=2,166). Perioperative outcomes and 30-day complication rates were measured and compared between cohorts. Multivariate logistic regression models determined if DEP status was an independent risk factor for adverse outcomes. A p-value of 0.05 was maintained for statistical significance.
Results: DEP patients were more likely to experience operative times >120 minutes (odds ratio [OR]=1.62; P<0.001), hospital stays >10 days (OR=2.33; P<0.001), and non-home discharge (OR=2.33; P<0.001). DEP status was also a risk factor for superficial surgical site infection (SSI; OR=1.81; P=0.012), deep SSI (OR=2.94; P=0.002), wound dehiscence (OR=2.74; P=0.001), cardiac arrest (OR=2.50; P=0.034), myocardial infarction (OR=2.27; P=0.009), pneumonia (OR=2.01; P=0.003), re-intubation (OR=2.14; P=0.021), stroke (OR=2.55; P=0.043), blood transfusion (OR=1.64; P<0.001), septic shock (OR=3.15; P=0.015), reoperation (OR=1.54; P=0.008), and readmission (OR=1.68; P<0.001).
Conclusions: Functionally dependent patients undergoing TKA are at higher risk of adverse outcomes and complications. This data may aid in preoperative patient counseling and risk stratification, especially as the indications for TKA continue to increase, such as in limited mobility populations.
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An Algorithm for Detection and Correction of Pelvic Tilt in Total Hip Replacement
Olivia J. Bono, BA, Clinical Research Fellow, Mehran S. Aghazadeh, MD, Surgical Assistant, James V. Bono, MD (ABOS), Clinical Professor, Department of Orthopedics, Vice Chair of Orthopedics, New England Baptist Hospital, Boston, Massachusetts
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Successful joint replacement surgery requires precise preoperative planning and intraoperative placement of implants such that the function of the joint is optimized biomechanically and biologically. The five-step “pelvic tilt algorithm” will enhance the outcome of hip replacement surgery as a result of improved acetabular component alignment. It will solve the problem of pelvic tilt as an unknown variable during hip replacement surgery, and will allow for more consistent and accurate acetabular component placement.
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A Systematic Review of Suture Technologies in Total Knee Arthroplasty
Anton Khlopas, MD, Resident, PGY – 1, Cleveland Clinic, Cleveland, Ohio, Hiba K. Anis, MD, Research Fellow, Assem A. Sultan, MD, Research Fellow, Cleveland Clinic, Cleveland, Ohio, Joseph Ehiorobo, MD, Research Fellow, Nipun Sodhi, MD, Research Fellow, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York
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Over time, various materials and techniques have been developed for superficial and deep wound closure. However, potential complications, such as infections and dehiscences, can still occur, driving the development of new closure modalities. As wound closure technology continues to advance and change, the need to continuously evaluate the current techniques and materials persists. Therefore, the purpose of this systematic review was to evaluate the current literature on the various closure materials and techniques utilized for total knee arthroplasty. Specifically, we evaluated: 1) closure times; 2) infections and complication rates; as well as 3) costs related to superficial and deep wound closures. Based on the findings from the current literature, barbed suture was associated with significantly shorter closing times in all five studies when compared to interrupted sutures (p<0.05). Additionally, the use of barbed sutures may result in similar postoperative complication rates. Although the cost of an individual barbed suture is potentially higher than the cost of an individual conventional suture, a knotless technique can require a shorter suture length, which might also help decrease costs.
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Operative Applications of Placental Tissue Matrix in Orthopaedic Sports Injuries: A Review of the Literature
Assem A. Sultan, MD, Clinical Research Fellow, Linsen T. Samuel, MD, MBA, Research Fellow, Alexander Roth, MD, Resident Physician, Bilal Mahmood, MD, Resident Physician, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Nipun Sodhi, BA, Research Fellow, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, Adjunct Staff, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Introduction: Placental and amniotic membrane-based tissues have gained widespread popularity for their ability to promote healing and tissue regeneration and have manifested multiple applications in wound care, burn treatment, and management of various ocular conditions. Recently, there have been multiple studies that investigated the nonoperative uses of placental tissue-based products in orthopaedic sports injuries. However, there is a relative paucity of studies that have attempted to evaluate their adjuvant operative uses. Therefore, the aim of this review was to evaluate the use of placental and amniotic tissue-based products as an adjuvant treatment to the operative management of orthopaedic sports injuries.
Materials and Methods: A comprehensive literature search was performed on PubMed, EBSCO Host, EMBASE, and SCOPUS. Studies published between January 1, 2000 and June 1, 2018 were reviewed. Inclusion criteria were that studies should have reported on: 1) operative uses of placental tissue matrix therapy in tendons and ligaments injuries; and 2) clinical outcomes; in 3) human subjects. In addition, the following studies were excluded: 1) animal studies; 2) basic science studies; 3) non-English language studies; 4) review studies; and 5) duplicate studies across databases. Additionally, to determine the various product compositions and indications for use, we searched publicly available manufacturer’s website content, marketing literature, FDA registration documents, and Center for Medicare and Medicaid Services submissions to assess the key differences for each of the products.
Results: Current evidence has led to investigation of various placental and amniotic membrane products used as an adjuvant treatment to surgical reconstruction of various types of tendon injuries, with a demonstrated effectiveness found mostly in the short-term, with follow up ranging between five weeks and two years. In addition, their safety and minimal complication profile have been demonstrated. Marked differences exist among the currently available products due to variations in their formulations, tissue source, processing methodology, sterilization method, preservation and storage methods, indications for use, and FDA regulation.
Conclusion: Operative uses of placental and amniotic membrane-derived tissues appear to be safe when utilized as an adjuvant or augmentation option along with surgical reconstruction. However, several factors may come into play when considering the diversity of commercially available products. Future clinical trials will need to confirm the safety and demonstrate clearer indications and specific guidelines for use in each clinical scenario involving operative management of tendon injuries. Nevertheless, this review will serve as an up-to-date reference and provide an impetus for future investigations.
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A Comparison of Pain Management Protocols Following Total Knee Arthroplasty: Femoral Nerve Block versus Periarticular Injectionof Liposomal Bupivacaine with an Adductor Canal Block
Sumeet Sandhu, BS, Medical Student, Jayson D. Zadzilka, MS, Research Coordinator, Emmanuel Nageeb, BS, Medical Student, Marcelo Siqueira, MD, Resident, Alison K. Klika, MS, Research Program Manager, Robert M. Molloy, MD, Staff Surgeon, Carlos A. Higuera, MD, Staff Surgeon, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Background: Total knee arthroplasty (TKA) results in significant postoperative pain and a demanding postoperative path for recovery. This study was conducted to determine whether a femoral nerve block (FNB) or a periarticular injection of liposomal bupivacaine with an adductor canal block (LB+ACB) is superior for pain management.
Materials and Methods: A total of 557 consecutive primary TKA cases performed at a single hospital between 2010–2014 were retrospectively reviewed. After enrollment criteria were met, 390 cases remained (FNB=181, LB+ACB=209). Inpatient and post-discharge variables related to pain, narcotic use, healthcare resource utilization, and cost were compared.
Results: There were no significant differences in demographics between the two groups. There was also no significant difference in inpatient postoperative pain between the two groups. The FNB group consumed fewer narcotics overall compared to the LB+ACB group (p<0.001). However, the LB+ACB group experienced fewer opioid-related adverse events (p<0.001). The LB+ACB group had a shorter length of stay (p<.001), fewer readmissions (p=0.017) and reoperations (p=0.025), and lower costs (p<0.001).
Discussion: LB+ACB proved to be an equally effective postoperative TKA pain management tool compared to FNB while displaying superiority in other increasingly important areas such as length of stay and cost. The larger amount of narcotic consumption is a concern, however, and there may be a small population of patients for whom LB+ACB is not the best option.
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Robotic-Arm Assisted Total Knee Arthroplasty More Accurately Restored the Posterior Condylar Offset Ratio and the Insall-Salvati Index Compared to the Manual Technique; A Cohort-Matched Study
Assem A. Sultan, MD, Research Fellow, Linsen T. Samuel, MD, MBA, Clinical Research Fellow, Anton Khlopas, MD, Resident Physician, PGY-1, Robert M. Molloy, MD, Orthopaedic Surgeon, Cleveland Clinic, Cleveland, Ohio, Nipun Sodhi, MD, Research Fellow, Michael A. Mont, MD, Director of Joint Arthroplasty, Lenox Hill Hospital, Northwell Health, New York, New York, Manoshi Bhowmik-Stoker, PhD, Senior Manager, Research – Reconstructive and Robotics, Stryker Orthopaedics, Mahwah, New Jersey, Antonia Chen, MD, Orthopaedic Surgeon, Brigham and Women’s Hospital, Boston, Massachusetts, Fabio Orozco, MD, Orthopaedic Surgeon, Rothman Institute, AtlantiCare, Atlantic City, New Jersey, Frank Kolisek, MD, Hip and Knee Surgeon, OrthoIndy Hospital, Greenwood, Indiana, Ormonde Mahoney, MD, Orthopaedic Surgeon, Athens Orthopaedic Clinic, Athens, Georgia, Langan Smith, BS, Research Coordinator, Arthur Malkani, MD, Orthopaedic Surgeon, KentuckyOne Medical Group, Louisville, Kentucky
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Introduction: Despite the demonstrated success of modern total knee arthroplasty (TKA), it remains a procedure that involves sophisticated preoperative planning and meticulous technique to reconstruct the mechanical axis, achieve ideal joint balance, and restore maximal range-of-motion (ROM). Recently, robotic-arm assisted TKAs have emerged as a promising new technology offering several technical advantages, and it is achieving excellent radiological results, including establishing the posterior condylar offset ratio (PCOR) and the Insall-Salvati Index (ISI). Studies have demonstrated that these parameters are surgically modifiable, and their accurate restoration (fewer mean differences) correlate with improved final joint range-of-motion. However, there is a paucity of studies that evaluate these parameters in light of performing robotic-arm assisted TKA. Therefore, in this study, we aimed to compare: 1) PCOR and 2) ISI restoration in a cohort of patients who underwent robotic-arm assisted versus manual TKA.
Materials and Methods: We evaluated a series of 43 consecutive robotic-arm assisted (mean age 67 years; range, 46 to 79 years) and 39 manual total knee arthroplasties (mean age 66 years; range, 48 to 78 years) performed by seven fellowship-trained joint reconstructive surgeons. All surgeries were performed using medial para-patellar approaches by high-volume surgeons. Using the Knee Society Radiographic Evaluation System, preoperative and four- to six-week postoperative radiographs were analyzed to determine the PCOR and patella height based on the ISI.
Results: The mean postoperative PCOR was larger in manual TKA when compared to the robotic-assisted cohort (0.53 vs. 0.49; p=0.024). The absolute mean difference between pre- and postoperative PCOR was larger in manual when compared to robotic-arm assisted TKA (0.03 vs. 0.004; p=0.01). In addition, the number of patients who had postoperative ISI outside of the normal range (0.8 to 0.12) was higher in the manual cohort (12 vs. 4).
Conclusion: Patients who underwent TKA using robotic-arm assisted technology had smaller mean differences in PCOR which has been previously shown to correlate with better joint ROM at one year following surgery. In addition, these patients were less likely to have values outside of normal ISI, which means they are less likely to develop patella baja, a condition in which the patella would impinge onto the patellar component, leading to restricted flexion and overall decreased ROM.
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Stratum-Specific Likelihood Ratio Analysis: An Evidence-Based and Pragmatic Approach to Meaningful Thresholds in Lower Extremity Arthroplasty
Sergio M Navarro, BS, Medical Student, Baylor College of Medicine, Houston, Texas, Said Business School, University of Oxford, Oxford, United Kingdom, Heather S Haeberle, BS, Medical Student, Baylor College of Medicine, Houston, Texas, Michael A. Mont, MD, Director of Joint Arthroplasty, Lenox Hill Hospital, Northwell Health, New York, New York, Viktor Krebs, MD, Orthopaedic Surgeon, Prem N. Ramkumar, MD, MBA, Resident Physician, PGY-3, Cleveland Clinic, Cleveland, Ohio
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Background: With the transition toward a value-based care delivery model, an evidence-based approach to quantify the effect of procedural volume on outcomes and cost presents an opportunity to understand and optimize the delivery of lower extremity arthroplasty. Stratum-specific likelihood ratio (SSLR) analysis has been recently applied to define benchmarks which confer a significant advantage in value at the hospital or surgeon level.
Materials and Methods: In this report, the role, statistical technique, and future applications of SSLR analysis are described with an example outlined for total hip arthroplasty (THA).
Results: SSLR analysis provides multiple significant value-based thresholds, providing an advantage over previous methods used to describe the effects of surgeon and hospital volume. These benchmarks have been developed for THA, total knee arthroplasty (TKA), hip fracture, and several other orthopaedic procedures. Current SSLR analyses are limited by the databases employed, and the study of a national database may provide more generalizable benchmarks, which may be applied by hospitals and orthopaedic residencies to define minimum competency thresholds.
Conclusion: The use of SSLR analysis provides a pragmatic, data-driven approach to understanding and communicating the volume-value relationship in orthopaedic surgery, particularly lower-extremity arthroplasty.
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Bilateral Femoral Neck Fractures in a Middle-Aged Female After a Low-Energy Fall
Ahmed Siddiqi, DO, MBA, Chief Orthopedic Surgery Resident, Salvador Forte, DO, Orthopedic Surgery Resident, John J. McPhilemy, DO, FAOAO, Attending Orthopedic Surgeon, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Andrew J Collier, MD, Attending Orthopedic Surgeon, Department of Orthopedics, Methodist Hospital Division of Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Background: Bilateral hip fractures after low-energy mechanism are a rare phenomenon. Most published case reports include presentations of bilateral hip fractures in the elderly with low-energy mechanism. There is no report, to our knowledge, that illustrates this rare occurrence in middle-aged individuals after a low-energy fall from standing height.
Case Presentation: We present a case of a 50-year-old female with history of cerebrovascular accident (CVA) who presented to our institution with bilateral valgus-impacted femoral neck fractures after a mechanical fall from standing height. The patient underwent successful in-situ percutaneous screw placement in bilateral hips.
Conclusion: Although patient age is an obvious risk factor, middle-aged individuals with a medical history affecting bone mineral content may also be prone to bilateral insufficiency fractures. Individuals complaining of joint pain (with a history of conditions including renal failure, obesity, endocrinopathies, etc.) should have advanced imaging, if screening plain radiographs are negative, in an effort to identify occult fractures.
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Survivorship and Radiographic Analysis of Highly Porous Acetabular Cups Designed for Improved Osseointegration Potential
Nipun Sodhi, MD, Research Fellow, Kristina Dushaj, MS, Research Manager, Matthew S. Hepinstall, MD, Orthopaedic Surgeon, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Anton Khlopas, MD, Resident, PGY – 1, Cleveland Clinic, Cleveland, Ohio, Zachary Berliner, MD, Resident Physician, PGY-1, Boston University Medical Center, Boston, Massachusetts, Jon E. Minter, MD, Orthopaedic Surgeon, Northside Hospital, Cumming, Georgia, Brandon Naylor, DO, Resident Physician, Mercy Health St. Vincent Medical Center, Toledo, Ohio, Robert Marchand, MD, Orthopaedic Surgeon, Ortho Rhode Island, South County Division, Wakefield, Rhode Island
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Introduction: A variety of highly porous materials have been used to obtain biological acetabular fixation after total hip arthroplasty (THA). Due to their improved surface-coated properties, new highly porous titanium metal implants have shown potential to promote prosthesis osseointegration. Therefore, the purpose of this multicenter study was to evaluate: 1) overall acetabular cup survivorship; 2) postoperative complications; and 3) radiographic signs of loosening and radiolucencies in patients who received a new highly porous titanium metal cup.
Materials and Methods: A total of 81 patients who underwent primary THA and received a new porous acetabular cup between May 16, 2013 and January 27, 2016 at three academic centers were included for analysis. There were 40 women (49%) and 41 men (51%) who had a mean age of 65 years (range, 38 to 95 years) and a mean body mass index (BMI) of 28 kg/m2 (range, 16 to 43 kg/m2). The minimum follow up time was two years and seven months (range, 2 to 4 years). The cup was engineered with fully interconnected porosity designed for potential long-term biologic fixation. Medical records were reviewed to assess for any revision surgeries and postoperative complications, and the most recent radiographs were reviewed for signs of loosening or radiolucencies.
Results: Overall, acetabular component survivorship, free of fixation failure or aseptic loosening, was 100%. Two patients underwent revision due to dislocations; however, revisions were performed because no constrained or dual mobility liners were available for the shell at the time. Both patients had successful outcomes and were doing well at final follow up with no further episodes of dislocation. There was one open reduction internal fixation for a periprosthetic femoral fracture, and three polyethylene revisions were performed for instability. In all of these cases, the acetabular cup was retained. On radiographic evaluation of antero-posterior pelvis radiographs, there was one patient who had radiolucencies of <1mm in Zone 1 and Zone 2 at 15 months after surgery, and another patient demonstrated radiolucencies of <1mm in Zone 2 and 3 at one-year follow up. At a minimum of two-year follow up, both patients had non-progressive and stable findings.
Conclusion: The results of this study demonstrated excellent survivorship, and there were no radiographic failures of this acetabular cup in primary total hip arthroplasty patients. Although two patients were found to have minimal (<1mm) radiolucencies, these were not progressive. Longer follow-up studies are needed to further assess the survivorship and outcomes of this new acetabular cup; however, based on the results of this study, these are expected to be favorable.
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Validation of the Hip Arthroscopy Module of the VirtaMed Virtual Reality Arthroscopy Trainer
Kieran Gallagher, MBBS, BSc (Hons), FRCS (Tr&Orth), Consultant Orthopaedic, Hip Trauma & Reconstruction Surgeon, Shayan Bahadori, BEng (Hons), MSc, Orthopaedic Research Institute Project Manager, Jop Antonis, MD, Orthopaedic Surgeon, Medinova Clinic Zestienhoven, Tikki Immins, BSc (Hons), MSc, Orthopaedic Research Institute Research Development Manager, Thomas W. Wainwright, PgDip, PgCert, BSc (Hons), MCSP, Deputy Head of Orthopaedic Research Institute, Robert Middleton, MA, MBBchir, FRICS, FRICS (Orth), CCST, Consultant Orthopaedic, Head of Orthopaedic Research Institute, Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK, The Royal Bournemouth and Christchurch, Hospitals NHS Foundation Trust, Bournemouth, UK
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Objective: To assess the face, content and construct validity of a virtual reality hip arthroscopy simulator (Arthros™, VirtaMed AG, Schlieren, Switzerland).
Design: Participants were divided into Expert and Novice groups depending on whether or not they had assisted with or performed more than 50 hip arthroscopy procedures. Participants were given a standardized introduction and shown a video on how to use the simulator. To familiarise themselves with the equipment, they were then given a 5-minute diagnostic task to complete. Participants then performed a therapeutic task. On completion, the simulator produced a summary of performance metrics for the following domains: Operation Time, Safety, Economy, Detailed Visualization and Overall Score. Participants completed a 7-point Likert-scale questionnaire to assess the face and content validity of the simulator.
Setting: University lab or exhibition stand at an orthopaedic conference.
Participants: Clinicians from a hospital orthopaedic department and attendees at a UK orthopaedic conference with varying levels of experience in hip arthroscopy surgery.
Results: Twenty-two participants were recruited. Six were classified as Expert and 16 as Novice. Statistically significant differences were found between the Expert and Novice groups for Overall Score (p=0.001), Safety (p=0.002) and Economy (p=0.033), but not Detailed Visualization (p=0.097). Questionnaire responses were positive for all items related to face and content validity.
Conclusion: This study suggests that training on the ArthroS™ VR hip arthroscopy simulator has construct, face and content validity. It expands the evidence base for VR simulator training and is the first study to evaluate this hip arthroscopy module.
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Reduced Thigh Pain with Short Femoral Stem Design Following Direct Anterior Primary Total Hip Arthroplasty
Nicola J. Horwood, BSc, Research Intern, Joint Implant Surgeons, Inc., New Albany, Ohio, Dennis Nam, MD, Orthopaedic Surgeon, Clinical Assistant Professor, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, Nicholas J. Greco, MD, Orthopaedic Surgeon, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, The Ohio State University, Wexner Medical Center, Columbus, Ohio, Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, The Ohio State University Wexner Medical Center, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, John C. Clohisy, MD, Professor, Charles M. Lawrie, MD, Assistant Clinical Professor, Washington University School of Medicine, St. Louis, Missouri, Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, President, White Fence Surgical Suites, LLC, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio
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Background: Thigh pain is a variably reported symptom in the postoperative period following primary total hip arthroplasty (THA) with a well-fixed cementless femoral implant. While research has identified stem size, stem alignment, and differences in modulus of elasticity between implant and host bone as potential sources of thigh pain, only one study has specifically examined the impact of variation in implant design within a single femoral stem design. The purpose of this work was to determine whether there were differences in the pain experienced by patients treated with two design variants of a femoral stem during direct anterior THA.
Materials and Methods: Patients undergoing primary direct anterior THA at a single center between 2011–2015 were included in the study. Those patients suffering extensive comorbidities and postoperative complications were excluded from analysis. Study subjects completed a pain drawing and scale questionnaire for the operative hip at least one year following surgery. A cementless, single-taper wedge, titanium femoral component design available in short- and standard-length variations was used in all cases. Pain outcomes were compared between these two femoral stem options.
Results: A total of 1347 patients (1536 THA) met inclusion criteria for the study and surveys were returned for 820 of these THAs. Demographic data and UCLA activity scores were similar between cohorts of patients receiving the short- and standard-length components. The most common locations of pain reported were in the lower back and trochanteric region, 28% and 24% respectively. Patients in the short-length cohort reported a significantly lower incidence of pain in the anterior thigh as compared to the standard-length cohort, 12% versus 19% respectively [p=0.007]. There was no difference in the number of patients experiencing moderate to severe intensity of anterior thigh pain between these two groups, 3% versus 5% respectively [p=0.36]. No other statistically significant differences were found in the incidence of pain in the lower back, buttock, groin, trochanter, lateral thigh, or posterior thigh regions between the two cohorts.
Conclusion: While the lower back and trochanteric region may be the most frequent areas of pain experienced in patients at one-year or more postoperative from direct anterior THA, a significantly higher incidence of anterior thigh pain is found in those patients treated with a standard-length stem design as compared to the short design. This finding may be due to contact between the tip of the distal stem with the femoral diaphysis as has been theorized in previous research, which is circumvented with the short design variant.
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Difficult Revision Total Hip Arthroplasty Cases Treated with an Offset Head Center Acetabular Shell
Andrew Wassef, MD, Medical Director, Orthopaedic Surgeon, MemorialCare Health System, Lakewood, California, Anton Khlopas, MD, Resident Physician PGY – 1, Assem A. Sultan, MD, Research Fellow, Morad Chughtai, MD, Resident Physician PGY – 2, Prem Ramkumar, MD, Resident Physician PGY – 3, Kim L. Stearns, MD, Orthopaedic Surgeon, Robert Molloy, MD, Orthopaedic Surgeon, Cleveland Clinic, Cleveland, Ohio, Nipun Sodhi, MD, Research Fellow, Michael A. Mont, MD, System Chief of Adult Reconstruction, Vice President Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York
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Acetabular bone loss is common during revision total hip arthroplasty (THA). A new acetabular shell was developed with a goal of maintaining native hip center-of-rotation (COR) while achieving good fixation with standard instrumentation and technique. Previous radiographic studies have demonstrated the efficacy of this shell in lowering hip COR. In this case series, we demonstrate the use of this shell in patients undergoing difficult revision THAs. Based on these cases, we have presented how this offset COR acetabular shell may help bring down the hip COR in patients who undergo revision total hip arthroplasty with severe bone loss.
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Tranexamic Acid Reduces Transfusion Rates in Obese Patients Undergoing Total Joint Arthroplasty
Morteza Meftah, MD, Chief of Adult Reconstruction Surgery and Clinical Research, Vinay H. Siddappa, MD, Fellow, BronxCare Hospital Center, Bronx, New York, Ira Kirschenbaum, MD, Chairman, Peter B. White, BA, Medical Student, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, Ahmed Siddiqi, DO, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
34/1109
Background: While tranexamic acid (TXA) has been well shown to reduce blood loss after joint replacement surgery, little is known regarding its effectiveness in obese patients. The aim of this study was to evaluate the effect of TXA changes in hematocrit and hemoglobin levels as well as incidence of packed red blood cell (pRBC) transfusions in obese patients undergoing total joint arthroplasty (TJA).
Material and Methods: Between January 2014 and May 2015, 420 consecutive primary joint replacements were performed by two surgeons at our institution. One-hundred-fifty-seven patients (total hip arthroplasty [THA]=29; total knee arthroplasty [TKA]=128) were obese with a body mass index (BMI) greater than or equal to 30 kg/m2. Medical records were reviewed and identified that TXA was utilized in 85 (54.1%) arthroplasties (study group) and was compared to a consecutive series of 72 (45.9%) TJAs (control group). TXA was given intravenously (IV) in two doses: (1) one gram prior to incision and (2) one gram at the time of femoral preparation in THA or prior to cementation in TKA. Changes in hemoglobin and hematocrit levels, number of pRBC transfusions, and occurrence of thrombolytic events were recorded.
Results: The changes in hematocrit (7.2% vs. 8.1%) and hemoglobin levels (3.0 g/dl vs. 3.3 g/dl) were less in the group that received TXA than the control group, albeit not significantly (p=0.100 and p=0.278, respectively). Within the control group, 26 (36.1%) patients required a pRBC transfusion with a mean of 2.0 units per patient (range:1–5); whereas, only eight (9.4%) patients with TXA required a mean of 1.6 units per patient (range: 1–2). The use of TXA significantly reduced the incidence of pRBC transfusions, especially in TKA (p<0.001). Sub-analyses revealed that transfusion rates were even more significantly reduced by TXA in obesity type II and III. Two pulmonary emboli were reported in the group that did not receive TXA; whereas, no thrombolytic events were reported in the group that did receive TXA.
Conclusion: Utilization of TXA significantly reduced the rate of pRBC transfusions in obese patients.
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Adjunctive Intravenous Diclofenac Decreases Opioid Consumption and Increases Satisfaction in the Primary Total Hip Arthroplasty Population
Nicole E. George, DO, Orthopedic Surgery Resident, Aultman Hospital, Department of Graduate Medical Education, Canton, Ohio, Cheryle Gurk-Turner, RPh, Clinical Pharmacy Specialist, Iciar M. Dávila Castrodad, MD, Research Fellow, Jennifer I. Etcheson, MS, MD, Research Fellow, Nequesha S. Mohamed, MD, Research Fellow, Ronald E. Delanois, MD, Chairman of Orthopedics, Alexandra N. Passarrello, BS, Research Assistant, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Chiemena U. Ohanale, BS, Research Assistant, Howard University College of Pharmacy, Washington, DC, Chukwuweike U. Gwam, MD, Physician Scientist, Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
34/1110
Despite the success of total hip arthroplasty (THA), postoperative pain management remains a concern. Although the nonsteroidal anti-inflammatory drug (NSAID) intravenous (IV) diclofenac is a promising addition, its impact on THA outcomes has not been investigated. This study evaluates the effects of adjunctive IV diclofenac on: 1) postoperative pain intensity; 2) opioid consumption; 3) discharge destination; 4) length of stay; and 5) patient satisfaction in primary THA patients. A retrospective study was performed for patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients of the study group (n=25) were treated postoperatively with IV diclofenac and the standard pain control regimen while the control group (n=88) did not receive diclofenac. Patients receiving adjunctive IV diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02; p=0.049). Patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the IV diclofenac group. Patients who received IV diclofenac had lower opioid consumption on postoperative days one and two (-67.2 and -129.0mg, respectively; p=0.001 for both). The growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. This study demonstrates that THA patients receiving adjunctive IV diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. To further investigate the optimal regimen, future studies comprising a larger cohort and comparing IV diclofenac to other NSAIDs are warranted.
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Development and Verification of a Porous Acetabular Shell Design Manufactured Using Additive Technology
Ahmad Faizan, PhD, Sr. Principal Engineer, Rob Davignon, BS, Staff Engineer, Robin Stamp, PhD, Sr. Manager, Sandra Murray, PhD, Sr. Staff Engineer, Lokesh Raja, MS, Manager, Stryker, Mahwah, New Jersey
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Introduction: Porous surface acetabular shells have been successfully used in cementless total hip arthroplasty. Recent advances in additive manufacturing have provided opportunities to optimize the shell designs. The current study describes the design and verification of a new acetabular shell design.
Materials and Methods: Additive manufacturing technology was used to fabricate acetabular shells using Ti6Al4V powder. A large computed tomography (CT) database was used to verify the screw hole location to ensure the screw trajectories were directed in the safe zone. Benchtop stability tests were conducted to compare the fixation stability of the new shell design to a clinically successful design.
Results: Shells were designed with an average pore size of 434 microns, surface porosity of 76%, and a coefficient of friction of 1.2. The CT analysis of various shell orientations demonstrated that at least two useful screws were typically directed toward the acetabular safe zone. The sawbone testing showed that the fixation stability of the new shell was either better or equivalent to the clinically successful design under two different bone preparation conditions.
Conclusions: Using additive manufacturing technology, thin walled acetabular shells were fabricated which allowed for at least two ancillary fixation screws in the safe zone. The thin walls enable the use of a 36mm femoral head with a 48mm diameter shell which may enhance the joint stability in small stature patients. The equivalent or better fixation stability of the new design indicates that good initial fixation may be expected in vivo.
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Primary Posterior Cruciate Ligament Repair With The Novel Suture Tape Augmentation Technique
Christiaan H. W. Heusdens, MD, Consultant Orthopaedic Surgeon, Sam Tilborghs, MD, Resident Orthopaedic Surgery, Lieven Dossche, MD, Consultant Orthopaedic Surgeon, Pieter Van Dyck, MD, PhD, Professor, Department of Radiology, Antwerp University Hospital, Edegem, Belgium
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Background: A posterior cruciate ligament (PCL) rupture is less common than an anterior cruciate ligament (ACL) rupture. PCL reconstruction remains controversial with variable outcomes and problems. The encouraging results of the novel ACL repair techniques led to renewed interest in PCL repair. Primary arthroscopic PCL repair has been rarely discussed and literature is scarce. To the best of our knowledge, no PCL repair patient outcome has been reported with one of the novel PCL repair techniques. We present the first case report of two patients who have been treated with the novel PCL repair technique, the suture tape augmentation technique.
Case description: Two patients who underwent primary PCL repair after an acute PCL rupture with a two-year follow up are presented. Patients were evaluated according to the Lysholm scale, the International Knee Documentation Committee (IKDC), and the Tegner activity scale. Follow up also included objective physical examinations—knee function and posterior drawer test using a rolimeter—and magnetic resonance imaging (MRI). Physical examinations were performed at three months, six months, one year, and two years after surgery.
Outcomes: At two-year follow up, both patients had a full range of motion and experienced no pain, nor swelling. IKDC scores were 83% (good) and 100% (excellent), Lysholm scores were 99 and 100 two years after surgery. At three months postoperative, the Tegner activity scale equaled the preinjury Tegner activity scale. One patient was horseback riding within three months. There were some increased posterior translation differences after two years—+2 and +3mm—compared with six weeks postoperative. MRI showed a healed PCL in both cases.
Discussion: PCL repair could be a promising treatment option for acute PCL ruptures. Advantages of this technique are the retaining of the natural proprioceptive capacities due to preserving native PCL fibers, the surgical technique is less invasive compared to a reconstruction, and no donor graft morbidity is expected as no graft is needed.
Conclusion: In these two cases, good subjective and objective results are demonstrated after PCL repair using the novel suture tape augmentation technique. MRI confirmed the healing of the PCL. Although this is a small case series, as PCL ruptures are less common compared to ACL ruptures, it is a stepping-stone for further PCL repair research.
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A Viable Osteochondral Allograft for Articular Cartilage Replacement of the First Metatarsal Head – A Case Series
Travis R Weber, DPM, Surgical Resident, Phillip Wrotslavsky, DPM, FACFAS, Board Certified Foot and Ankle Reconstruction, American Board of Foot and Ankle Surgery, Resident Teaching Staff, Department of Foot and Ankle Surgery, Scripps Mercy San Diego Hospital, San Diego, CA
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Few reports in the literature have described the use of an osteochondral allograft for the treatment of articular cartilage damage of the 1st metatarsal phalangeal joint. We present here the clinical outcomes and detailed surgical technique of four cases in which we used a cryopreserved, viable, osteochondral allograft (CVOCA) for full cartilage replacement of the first metatarsal head to address degenerative articular cartilage damage. At 10-22 months of follow-up, patients reported clinical improvement, with VAS pain-scale scores decreasing from an average of 8.0 to 0 post-operatively, and range-of-motion improvement from an average of 4.3 degrees to 58.3 degrees dorsiflexion. Radiographic improvement was also seen, with an increase in average joint space from 1.1mm, 1.5mm, and 2.2mm from medial to lateral on dorsoplantar views pre-operatively, to 3.1mm, 2.8mm, and 3.1mm 15 months post-operatively, respectively. These results suggest that CVOCA is a desirable treatment option for end-stage degenerative joint disease of the first metatarsal phalangeal joint.
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Spontaneous Closed Rupture of Achilles Tendon Following Minimally Invasive Ultrasonic Energy Therapy: Report of Two Cases
Danielle Gurin, DO, Resident Physician, Assem A. Sultan, MD, Clinical Research Fellow, Mark Berkowitz, MD, Orthopaedic Surgeon, Sara Lyn Miniaci-Coxhead, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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This paper presents two patients who sustained spontaneous closed Achilles tendon ruptures following minimally invasive ultrasonic energy therapy for non-insertional Achilles tendinopathy. In both cases, the patients underwent minimally invasive ultrasonic energy therapy using a commercially available device. In addition, the current evidence, through available literature, has been reviewed and presented.
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Multimodal Treatment in Pelvic Ewing Sarcoma: A Prognostic Factor Analysis
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Francesca Totti, MD, Specialist in Orthopedics and Traumatology, Pierluigi Cuomo, MD, Specialist in Orthopedics and Traumatology, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Davide Matera, MD, Specialist in Orthopedics and Traumatology, Giuliana Roselli, MD, Specialist in Radiology, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, Angela Tamburrini, MD, Specialist in Pediatric Oncology, Myer Hospital, Florence, Italy, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and Traumatology, Pisa, Italy
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BACKGROUND: Although multidisciplinary therapies have improved local control and overall survival in Ewing sarcoma (ES), the prognosis of pelvic lesions remains markedly worse than that of limb ES. METHODS: We retrospectively evaluated the influence of the type of local treatment, margins, necrosis and sacrum involvement on overall survival (OS) and disease-free survival (DFS) in a series of 21 non-metastatic pelvic ES.
RESULTS: The average follow-up was 46.3 months (range 3-156). Only one patient had recurrence, at 11 months after surgery. Eight patients showed pulmonary metastasis and five showed bone metastases. Necrosis was the only significant prognostic factor for overall survival at 5 years (p=0.0132) and disease-free survival (p=0.0086). Overall survival at 5 years was 40.1%.
CONCLUSION: Local control in pelvic Ewing sarcoma is comparable for patients treated with surgery (S), surgery plus radiotherapy (S/RT), or definitive radiotherapy (RT). The combination of surgery plus radiotherapy could be indicated in cases of large tumor, a poor necrosis response (< 90%), or an inadequate margin with involvement of the sacrum. A poor response to neoadjuvant therapy is a significant risk factor for both local control and overall survival.
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Robotic-Assisted Total Knee Arthroplasty in the Presence of Extra-Articular, Deformity
Nipun Sodhi, MD, Research Fellow, Joseph O. Ehiorobo, MD, Research Fellow, Joseph O. Ehiorobo, MD, Research Fellow, Matthew S. Hepinstall, MD, Orthopaedic Surgeon, Lenox Hill Hospital, Northwell Health, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Anton Khlopas, MD, Resident Physician, PGY-1, Cleveland Clinic, Cleveland, Ohio, Caitlin Condrey, Kevin Marchand, BS, Robert C. Marchand, MD, Wakefield, Rhode Island
34/1114
Introduction: Tibial or femoral extra-articular deformities complicate the goal achieving optimal mechanical axis alignment for successful total knee arthroplasty (TKA) outcomes. In the presence of these extra-articular deformities, standard operative techniques and instruments may not be reliable. Robotic-arm assisted technology was developed to help achieve a well-aligned and balanced knee in a variety of clinical scenarios. Although prior case series have reported on the use of robotic-arm assisted devices for cases with severe angular deformity, there is a lack of data concerning the use of the robotic device for patients with other potentially complex surgical factors. Therefore, the purpose of this series was to present cases in which the robotic-arm assisted TKA application was used in the setting of extra-articular deformities to educate the surgeon community on this potentially useful method to address these complex cases.
Materials and Methods: Three cases of patients who underwent robotic-arm assisted TKA in the setting of preoperative extra-articular deformities were identified. These included one with femoral and tibial fracture malunion, another with a proximal tibial fracture nonunion, and another with a healed tibial plateau fracture. Patient clinical histories, intraoperative surgical techniques, and postoperative outcomes were obtained. Specific focus was placed on the surgical management of the patient’s pre-existing deformity.
Results: These three case reports are discussed in detail, with emphasis on preoperative planning and intraoperative techniques. The robotic software was able to appropriately consider the extra-articular deformity in the preoperative and real-time updated intraoperative plans. Doing so, the surgeon was able to achieve balanced and aligned TKA in each case. All three patients underwent robotic-assisted total knee arthroplasty with no intraoperative or postoperative complications. For all patients, their anteroposterior and lateral radiographs demonstrated well fixed and aligned femoral and tibial components with no signs of loosening or osteolysis. On physical exam, all patients had excellent range-of-motion with mean flexion of 122° (range: 120 to 125° of flexion) at final follow up.
Discussion: The decision on how to best approach TKA in patients with extra-articular deformity should be based on an extensive patient history, physical examination, and thorough evaluation of the magnitude and proximity of the deformity to the knee joint. Utilizing preoperative CT-scans with a 3D plan for robotic-arm assisted surgery allowed for appropriate assessment of the deformity preoperatively and execution of a plan for a balanced and aligned total knee arthroplasty. We have demonstrated excellent results utilizing robotic-arm assisted TKA in these complex cases.
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The Center-Center Technique for the Direct Anterior Approach in Total Hip Arthroplasty: Precise Femoral Canal Preparation to Optimize Implant Fit and Fill
Peter Gold, MD, Orthopaedic Resident – PGY-3, Luke Garbarino, MD, Orthopaedic Resident – PGY-3, Spencer Stein, MD, Orthopaedic Resident – PGY-5, Sreevathsa Boraiah, MD, Assistant Professor, Levi Brown, BA, Long Island Jewish Medical Center, Northwell Health, New York, New York, Mark Jones, MD, Resident Physician, Beth Israel Deaconess Medical Center, Boston, Massachusetts, Nipun Sodhi, BA, Research Fellow, Michael A. Mont, MD, System Chief of Adult Reconstruction, Vice President Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York
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Background: The use of the direct anterior approach has been criticized as a significant risk factor for subsidence, perioperative fracture, and thigh pain. Therefore, the purpose of our study was to evaluate the outcome of using the center-center technique via the direct anterior approach.
Materials and Methods: Consecutive elective primary total hip arthroplasties performed using the center-center technique were retrospectively reviewed from May 2015 to February 2017. All cases were performed by a single surgeon at a high-volume, large academic center. The technique focuses on central alignment of the implant on both anteroposterior and lateral radiographs. Standardized objective radiographic measurements were taken at the first two-week follow-up visit to determine the fit and fill at the proximal and distal anatomic segments. Subsidence was measured by comparing the implant position at final follow up to the initial two-week postoperative visit. Other complications: intra- or postoperative fracture, infection, revision, and patient-reported thigh pain were further assessed. Functional postoperative outcomes were assessed using the Harris Hip Score (HHS).
Results: A total of 138 patients with a mean age of 65 years and average follow up of 2.8 years were assessed. The mean postoperative HHS was 90 points (59–100). Mean implant subsidence was 1mm. A total of 90% (124) of implants had acceptable radiographic fit and fill in both proximal and distal segments. A majority 74% (102) of implants subsided less than 1mm, and 91% (126) subsided less than 2mm. One implant had radiographic subsidence of 9mm, which was treated with a shoe lift. There were no intraoperative fractures. One postoperative lateral cortex fracture three weeks after surgery due to mechanical fall was treated conservatively. No patients required revision arthroplasty for any reason or reported postoperative thigh pain.
Conclusion: The center-center technique can be used to consistently aid in proper femoral stem placement in both coronal and sagittal planes. Optimal fit and fill can be achieved safely using this technique.
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Injection Alternatives for the, Management of Knee Osteoarthritis Pain
Bumsup Lee, DVM, PhD, President and Chief Executive Officer, Kolon TissueGene, Inc., Rockville, Maryland, Nipun Sodhi, MD, Research Fellow, Joseph O. Ehiorobo, MD, Research Fellow, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Hiba K. Anis, MD, Research Fellow, Cleveland Clinic, Cleveland, Ohio
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Introduction: There has been a rapid increase in opioid-related morbidity and mortality worldwide, and the dangers of excessive opioid use have been observed in patients with chronic musculoskeletal pain, including those diagnosed with knee osteoarthritis. Pain management is an important component of nonoperative treatment in knee osteoarthritis and frequently entails the use of opioids. However, this management technique is not without risks, such as addiction, morbidity, and mortality. Therefore, the purpose of this study was to review the existing literature on the use of opioids in the management of knee osteoarthritis and compare the findings to a new injection management modality. Specifically, we assessed: 1) trends in opioid prescription; 2) patient-reported outcomes; 3) incidence of complications; 4) incidence of abuse and dependence; and 5) mortality related to opioid use in knee osteoarthritis. We then performed a sub-analysis comparing these findings to TG-C, a novel a 3:1 mixture of genetically engineered chondrocytes that has shown promising early phase I, II, and III results.
Materials and methods: A literature search was performed utilizing the PubMed database with search terms including, but not limited to: “knee osteoarthritis,” “total knee arthroplasty,” “opioid,” “annual trends,” “outcomes,” “complications,” “dependence,” “mortality,” and “deaths”. The initial search revealed 548 results, with an additional 182 sources added after reviewing associated references. After removing duplicates, 245 records were reviewed after which results were evaluated and stratified based on outcomes, yielding a total of 35 studies for final evaluation. Correlative and comparative analyses were performed evaluating trends in opioid prescription, patient-reported outcomes, incidence of complications, incidence of abuse and dependence, and mortality related to opioid use in knee osteoarthritis. Additionally, for each of the aims studied, a summative discussion relating study findings to clinical practice was performed. Outcomes from phase II and III trials of genetically engineered chondrocytes (GEC) injections were also analyzed with a focus on pain reduction.
Results: Nearly all studies report markedly increasing trends in opioid prescriptions, with some studies showing significant incremental increases in prescription rates (31 vs. 40%) over time. Additionally, projection models predict—based on current rates of prescribing opioids—that by 2030, prescriptions will triple from 1.1 million in 2015 to 3.0 million in 2030. Along with this, mean oral morphine equivalent dosages will also increase by 22% over a 15-year period. When evaluating patient-reported outcomes, multiple studies have found no significant differences in patient-reported pain outcomes between opioid and non-opioid users (p>0.05). In fact, many studies even report poorer outcomes in patients who used opioids prior to surgical interventions. Opioid use was found to also be associated with increased referrals to pain management, longer in-hospital stays, and poorer Knee Society scores after total knee arthroplasty (TKA) (p<0.05). Furthermore, some studies report as high as 42% of patients continue to use opioids after the initial 90-day postoperative period, and epidemiologic data for the United States reveals an over 20x increase in opioid-related deaths from 0.3 to 6.2 per 100,000 between 1999 and 2016.
Our sub-analysis revealed that GEC injections were found to significantly improve reductions in visual analog scale (VAS) pain (-37.2 vs. -23.4 mm, p<0.05) and International Knee Documentation Committee (IKDC) scores (23.0 vs. 12.7, p<0.05) between study and control cohorts, indicating this injection modality to potentially be a successful non-opioid based management technique that is safe and effective. Discussion: The effects of the opioid epidemic on patients with knee osteoarthritis are severe. Excessive opioid use in these patients leads to poorer patient satisfactions as well as increased morbidities and mortalities. Therefore, there is a real need for alternative nonoperative treatment options that effectively reduce pain, and promising results from studies on the efficacy GEC injections demonstrate that they may be an answer to the opioid epidemic observed among osteoarthritis patients.
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Performance on a Virtual Reality DHS Simulator Correlates with Performance in the Operating Theatre
Mr. Kalpesh R. Vaghela, MBBS BSc MSc MRCS, Trauma & Orthopaedic Registrar, Percivall Pott Rotation, Mr. Joshua Lee, BSc (Hons) MBChB, MSc, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Mr. Kash Akhtar, MBBS, BSc, MEd, MD, FRSA, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London
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Introduction: Dynamic Hip Screw (DHS) fixation of neck of femur fractures is one of the most commonly performed orthopaedic trauma operations. Changes in working practices have impacted surgical training and have resulted in fewer opportunities to perform this procedure. Virtual reality (VR) simulation has been shown to be a valid means of gaining competency, efficiently and safely, without compromising patient safety. Objective: The aim of this study is to determine whether performance on a VR DHS simulator orrelates with performance in the operating theatre.
Materials and Methods: All episodes of DHS fixation of neck of femur fractures performed at Royal London Hospital, Barts Health NHS Trust, level 1 major trauma centre between January 2014 and December 2015 were identified using the hip fracture database. The primary surgeon was identified using the electronic operative notes. The intraoperative fluoroscopic images were accessed and the tip-apex distance (TAD) was measured, as well as the probability of cut-out. The surgeon then performed DHS fixation on a VR DHS simulator and the TAD achieved in theatre was correlated with the simulated TAD.
Results: Twenty-five surgeons, including six novices (core surgical trainees), 12 intermediates (specialist registrars), and seven experts (fellows and consultants), completed the study. There was no overall statistically significant difference in TAD between those achieved in the operating theatre and on the simulator for each participant (p=0.688).
Conclusion: There is no significant difference between performance on a VR DHS simulator and the operating theatre. This suggests that the simulator is excellent for training in this component of the DHS procedure, but further work is needed to assess whether training on the simulator can improve performance in the operating theatre.
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Linear Wear Rates of a Highly Cross-Linked Polyethylene Hip Liner
Nipun Sodhi, BA, Research Fellow, Michael A. Mont, MD, System Chief of Joint Reconstruction, Vice President, Strategic Initiatives, Lenox Hill Hospital, Northwell Health, New York, New York, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Research Fellow, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Fellow, SUNY Downstate Medical Center, Brooklyn, New York, Charles Jaggard, MS, Clinical Trial Manager, Frank Kolisek, MD, Orthopaedic Surgeon, OrthoIndy, Greenwood, Indiana
33/1023
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Effects of Coronal Limb Alignment and Ligament Balance on Pain and Satisfaction Following Total Knee Arthroplasty at Short-Term Follow Up
Ahmed Siddiqi, DO, MBA, Orthopedic Surgery Resident, Peter B. White, BS, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, Lisa Kaplin, DO, Orthopedic Surgery Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, James V. Bono, MD, Clinical Professor of Orthopedic Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts, Carl T. Talmo, MD, Assistant Professor of Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts
33/1035
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Clinical Results of Direct Anterior Approach THA with Minimal Fluoroscopic Exposure Optimization Techniques
Sergio M. Navarro, BS, Christopher Frey, BS, Baylor College of Medicine, Houston, Texas, Terri Blackwell, PA, Orthopedic Joint Reconstructive Surgery Specialist, Sarah B. Voges ANP, Orthopedic Joint Reconstructive Nurse Practitioner, H. Del Schutte Jr. MD, FAOA, Comprehensive Joint Program Medical Director, Department of Orthopedics, Charleston Institute for Advanced Orthopedics, Charleston, South Carolina
33/1028
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Is an Intramedullary Nail a Valid Treatment for Limb-Length Discrepancy After Bone Tumor Resection? Case Descriptions
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Guido Scoccianti, MD, Specialist in Orthopedics and Traumatology, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Davide Matera, MD, Specialist in Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and Traumatology, Pisa, Italy, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
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One of the most frequent outcomes after resection of bone tumors in children is a limb-length discrepancy. An intramedullary nail is a valid method for lengthening the limb. We report our experience with four cases of limb-length discrepancy in the lower limbs several years after the primary treatment of bone tumor resection and subsequent reconstruction. Two femoral PRECICE® nails (NuVasive, Inc., San Diego, CA) were introduced retrograde and two were introduced in an anterograde manner. All four cases healed and showed a reduction of the limb-length discrepancy, early loading, and complete bone osteogenesis. In one case, a reduction of the joint ROM recovered after release of the iliotibial band and a quadriceps release according to Judet’s arthrolysis.
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Capsular Sparing Total Hip Replacement Technique Applied with a Dual-mobility Cup to Reduce Dislocations
H. Morton Bertram III, MD, Chief Orthopaedic Surgeon, Naples Community Hospital, Naples, Florida, Megan E. Bertram, Trainee, Northern Kentucky University, Highland Heights, Kentucky, Laura Scholl, MS, Manager, Manoshi Bhowmik-Stoker, PhD, Senior Manager, Clinical Research Department, Stryker Orthopaedics, Mahwah, New Jersey, Michael T. Manley, FRSA, PHD, President, Michael T. Manley, LLC, Wyckoff, New Jersey
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Regardless of the surgical approach used, dislocation remains a complication following total hip replacement. In recent years, newer technologies, such as the use of large femoral heads, have reduced the rate of postoperative dislocation. The combination of such technology, together with a soft tissue repair technique, may reduce the dislocation rate even further.
A single surgeon performed 513 primary total hip replacements on 505 patients using a posterior approach utilizing a technique designed to spare the capsule. There were 257 males and 248 females. Age ranged from 39 to 92 years. Surgeries were performed from January 2012 to December 2015. Implants used were cementless dual-mobility cups and cementless femoral stems. In all cases, the posterior capsule was incised and retracted, but not excised. Following implant placement, the capsule was repaired using a fiber reinforced suture. The superior border of the capsular incision, just above the piriformis, was sutured to the superior capsule or gluteus minimus muscle. The intent of this repair was to completely incarcerate the femoral head. Patients were followed at two weeks, six weeks, three months, one year, three years, and five years. Follow up was one to five years post-implantation. The dislocation rate was zero. The combination of a large dual-mobility femoral head, combined with a soft tissue repair that spares the deep capsule, has the potential to significantly reduce dislocation rates when using the posterior approach to the hip.
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Acromioclavicular Joint Stabilisation Using the Internal Brace Principle
Paul A. Byrne, MEng, MSc, MBChB, Specialty Registrar, NHS South-East Scotland, Edinburgh, Scotland, Graeme P. Hopper, MBChB, MSc, MRCS, Specialty Registrar, Trauma and Orthopaedics, William T. Wilson, MBChB BSc(Med.Sci) MRCSEd, Specialty Registrar/ Honorary Clinical Lecturer, Gordon M. Mackay, MD, FRCS(Orth), FFSEM(UK) , Consultant Surgeon, Orthopaedics Department, Ross Hall Hospital, Glasgow, Scotland
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Introduction: Injury of the acromioclavicular joint (AC joint) is one of the most common conditions affecting the shoulder girdle in athletes, particularly in contact sports. It is generally agreed that surgical management provides superior outcomes in high-grade injuries (Rockwell Grades IV–VI), with nonoperative management preferred in low-grade injuries (Grades I–II). Controversy still exists regarding the optimal treatment for Grade III injuries, with various sources reporting quicker return to activity and reduced complications with nonoperative management, but superior long-term function and satisfaction in cases managed surgically. Mean predicted return to sporting action in surgical cases varies in the literature from four months to 9.5 months.
Case Description: This retrospective case report follows a 28-year-old male Scottish Premiership professional football player after he suffered a Grade III AC joint dislocation whilst playing in a European club match. He was managed operatively using a novel minimally invasive surgical technique using the principles of internal brace ligament augmentation.
Results: This player resumed full first-team action exactly three months post-surgery. After more than two years of follow up, he has experienced no complications or re-injury of the shoulder and has maintained his previous level of performance.
Conclusion: This case represents an exceptional recovery to high-level sporting performance. The novel repair method was key to this success in allowing early mobilisation of the shoulder and could offer improved results to high-level athletes suffering such injuries.
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Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience
Olivia J. Bono, BA, Clinical Research Coordinator, Chris Damsgaard, MD, Arthroplasty Fellow, Claire Robbins, PT, DPT, MS, Research Assistant, Mehran Aghazadeh, MD, Surgical Assistant, Carl T. Talmo, MD, Vice Chair for Orthopedic Research, James V. Bono, MD, Vice Chair for Orthopedics, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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Background: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period.
Materials and Methods: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA.
Results: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient’s perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%.
Conclusion: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient’s perception of pain and recovery is dramatically improved with preservation of the iliotibial band.
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Ultrasound-Guided Calcium Debridement of the Shoulder Joint: A Case Series
Edward Milman, MD, Associate Professor, Todd P. Pierce, MD, PGY-2 Orthopaedic Surgery Intern , Kimona Issa, MD, PGY-5 Orthopaedic Resident, Robert R. Palacios, BS, Undergraduate Research Volunteer , Anthony Festa, MD, Associate Professor, Anthony J. Scillia, MD, Associate Professor, Vincent K. McInerney, MD, Residency Program Director, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey
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Objective: Our purpose was to assess the outcomes of those who underwent an ultrasound-guided debridement of the deposits. Specifically, we analyzed: (1) function; (2) pain; (3) activity level; (4) patient satisfaction; and (5) complications.
Materials and Methods: A review of patients who underwent an ultrasound-guided debridement of calcific deposits about their shoulder joint between 2005 and 2015 was performed. Our final cohort consisted of 38 patients with a mean age of 53 years (range, 35 to 62 years)—11 men and 27 women—and a mean follow up of 32 months (range, 12 to 53 months). Functional outcomes, activity level, and pain level were assessed using the Disabilities of Arm, Shoulder, and Hand (DASH) scale, the University of Southern California (UCLA) activity scale, and the Visual Analog Scale (VAS). Additionally, patients were asked if they were satisfied with the outcomes of their procedure. All medical records were assessed for potential complications from this procedure.
Results: Excellent outcomes were achieved. The mean DASH score improved from 21 to 10 points (p=0.0001). Additionally, mean UCLA score increased from 2 to 7 points (p=0.0001). Furthermore, the mean reported VAS improved from 8 to 1.6 (p=0.0001). Ninety-seven percent of patients reported being satisfied. There were no reported complications in our cohort.
Conclusion: We found that this procedure can result in effective pain relief and prevent or delay the need for more invasive procedures. Future studies should evaluate the role of calcium deposit size in the outcomes of those who undergo debridement.
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Anterolateral Ligament of the Knee: What we Know About its Anatomy, Histology, Biomechanical Properties and Function
Thomas Neri, MD, PhD, Doctor of Surgery, Frederic Farizon, MD, Professor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France, EA 7424 - Inter-university Laboratory of, Human Movement Science, Université de Lyon - Université Jean Monnet, Saint Etienne, France, Sydney Orthopaedic Research Institute, Sydney, Australia, David Anthony Parker, BMedSci, MBBS, FRACS, FAOrthA, Associate Professor of Surgery, University of Sydney, Director of Research, Sydney Orthopaedic Research Institute, Sydney, Australia, Aaron Beach, PhD, Research assistant, Sydney Orthopaedic Research Institute, Sydney, Australia, Bertrand Boyer, MD, PhD, Doctor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France
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To better control anterolateral rotational instability (ALRI) after anterior cruciate ligament reconstruction (ACLR), many recent studies have examined the anterolateral ligament (ALL). Although some inconsistencies have been reported, anatomic studies demonstrated that the ALL runs on the lateral side of the knee from the femoral lateral epicondyle area to the proximal tibia, between Gerdy’s tubercle and the fibula head. Histologic research has characterized the ALL structure, which is more than a simple capsular thickening; it shows a dense collagen core, typical bony insertions and mechanoreceptor function. An analysis of biomechanical properties suggests that the ALL is weaker than other knee ligaments. While its contributions to tibial anterior translation control and to a high grade on the Pivot-Shift test are still unclear, there is a consensus that the ALL controls tibial internal rotation. Further research will be needed to clarify the significance of ALL injuries and to gauge the value of combined ACL and ALL reconstructions.
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Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty
Ahmed Siddiqi, DO, MBA, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Peter B. White, BS, Medical Student, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, William Murphy, MS, Medical Student, Harvard Medical School, Cambridge, Massachusetts, Dave Terry, MBA, CEO, Founder, Archway Health, Boston, Massachusetts, Stephen B. Murphy, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Carl T. Talmo, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts
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Background: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization—a group of private practices partnering with a consultant—aimed to analyze the impact of a preoperative protocol on overall cost savings. Materials and Methods: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009–2014 were compared with 408 consecutive BPCI patients from 2014–2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission. Results: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions. Conclusion: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.
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Loss of Functional Internal Rotation Following Various Combinations of Bilateral Shoulder Arthroplasty
Jacob J. Triplet, DO, PGY-2 Orthopaedic Surgery Resident, OhioHealth Doctors Hospital, Columbus, OH, Jennifer Kurowicki, MD, Orthopaedic Surgery Research Fellow, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, Derek D. Berglund, MD, Orthopaedic Surgery Research Fellow, Jonathan C. Levy, MD, Chief of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL, Samuel Rosas, MD, Orthopaedic Physician Scientist, Wake Forest School of Medicine, Winston-Salem, NC, Brandon J. Horn, DO, Orthopaedic Surgeon, Witham Orthopaedic Associates, Lebanon, IN
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Background: Limited internal rotation (IR) remains a concern for activities of daily living (ADLs) following bilateral shoulder arthroplasty (BSA). The purpose of this study was to evaluate the loss of the ability to perform functional IR tasks following BSA using various combinations of anatomic (TSA) and reverse (RSA) shoulder arthroplasty.
Methods: A retrospective review of an institutional shoulder-surgery database was conducted for patients who underwent BSA with any combination of TSA or RSA with at least a 2-year follow-up. IR range of motion (ROM) and individual American Shoulder and Elbow Surgeons (ASES) score and Simple Shoulder Test (SST) questions specific to IR were used to assess a patient’s ability to perform IR tasks with at least one of their shoulders.
Results: Seventy-three patients met the inclusion criteria (47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA). Average age at surgery was 72.1 years. Average follow-up was 51.4 months. Loss of ability to wash one’s back was observed in 30.4% TSA/TSA, 33.3% TSA/RSA, and 52.9% RSA/RSA. Loss of ability to tuck in a shirt was observed in 10.6% TSA/TSA, 11.1% TSA/RSA, and 29.4% RSA/RSA. Loss of ability to manage toileting was observed in no TSA/TSA or TSA/RSA, but in 11.8% RSA/RSA. For each of the tasks, there were no significant differences in the ability to perform the task among the groups (p>0.05). Post-operative IR ROM for TSA/TSA was superior to those for TSA/RSA and RSA/RSA (p<0.01). IR ROM efficacies for both RSA/RSA and TSA/RSA were inferior to that for TSA/TSA (p<0.05).
Conclusion: Bilateral RSA patients can perform most IR tasks, and their ability to complete these tasks does not differ significantly from those in patients with other BSA.
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Outcomes of Revision Joint Arthroplasty Due to Metal Allergy and Hypersensitivity: A Systematic Review
Julio J. Jauregui, MD, Orthopaedic Surgery Resident, Shivam J. Desai, MD, Orthopaedic Surgery Resident, Arun Hariharan, MD, Orthopaedic Surgery Resident, Farshad Adib, MD, Orthopaedic Surgeon, University of Maryland Medical Center, Baltimore, Maryland, Vaughn Hodges, MD, Resident Physician, University of California San Francisco, San Francisco, California, Jared M. Newman, MD, Orthopaedic Surgery Resident, Aditya V. Maheshwari, MD, Director, Adult Reconstruction and Musculoskeletal Oncology Divisions, SUNY Downstate Medical Center, Brooklyn, New York
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Background: Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could fail due to various well-known causes. Furthermore, metal allergy-related complications have recently gained attention as one of the potential causes of failure when the common reasons have been excluded. Reported symptoms from metal allergy can include chronic eczema, joint effusions, joint pain, and limited range of motion. Few studies have explored the outcomes of patients undergoing revisions due to allergic complications. The aim of our study is to quantitatively evaluate the outcomes of revision joint arthroplasty due to metal allergy and hypersensitivity.
Materials and Methods: A comprehensive literature search using MEDLINE (PubMed), Ovid, and Embase was systematically performed to evaluate all studies included in the literature until December 2015. The search terms used were “Arthroplasty,” “Allergy,” “Revision,” “Allergic Reaction,” and “Hypersensitivity,” and a total of 414 studies were identified. After a thorough review, five studies ultimately met the inclusion criteria and were included in the final review. This was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results: A total of 44 total knee arthroplasty (TKA) revisions and three total hip arthroplasty (THA) revisions due to metal allergy were reported. All of the implants used during the primary procedures were cobalt chromium blends, and bone cement was used in all but three cases (93%). Allergen testing was performed using patch testing, modified lymphocyte stimulation test (mLST), or lymphocyte transformation testing (LTT) in all cases. Of the four studies which reported results, positive sensitizations were most commonly seen with nickel (87% of cases), followed by cobalt (37%) and chromium (reported in one study, ~10%). Following revision surgery, 100% of cases experienced symptomatic relief.
Conclusions: Overall, we found that properly selected patients with allergy-related symptoms can benefit from undergoing a revision TJA with replacement to components void of the offending allergen metals. Appropriate revision surgery provided universal resolution of symptoms and improved functional outcomes.
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Accurately Predicting Total Knee Component Size without Preoperative Radiographs
Steven M. Teeny, MD, Manoshi Bhowmik-Stoker Ph.D, Orthopedics Service, Madigan Healthcare System, Tacoma, Washington, Laura Scholl, MS, Stryker, Joint Replacement Division, Mahwah, New Jersey, Anton Khlopas, MD, Michael A. Mont, MD, Cleveland Clinic, Cleveland, Ohio, Lenox Hill Hospital, New York, New York
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Background: Preoperative templating of total knee arthroplasty (TKA) components can help in choosing appropriate implant size prior to surgery. While long limb radiographs have been shown to be beneficial in assessing alignment, disease state, and previous pathology or trauma, their accuracy for size prediction has not been proven. In an attempt to improve templating precision, surgeons have looked to develop other predictive models for component size determination utilizing patient characteristics. The purpose of this study was to: 1) Identify which patient characteristics influence the tibial and femoral component sizes; 2) Construct models for size prediction; 3) Test the generated models at five different centers; and 4) Compare implant survivorship and patient characteristics between those who did or did not receive an implant within one size of the prediction.
Materials and Methods: Demographic data was collected on 741 patients (845 knees) as part of a multicenter clinical trial. Correlation between component size and patient demographic data were examined using Pearson coefficients, and significant variables were included into a multivariate-linear-regression model to determine “predicted size.” Operative surgeon notes and postoperative radiographs were used to determine “actual size.” Predictive equations were constructed for both femoral and tibial components and were tested at five different centers. Implant survivorship and patient characteristics were compared between those who did and did not receive an implant within one size of the prediction.
Results: The strongest predictors of component size were height, weight, and gender (p<0.01), followed by ethnicity (p=0.03) and age (p=0.03). Predictive equations were constructed for both tibial and femoral components. The model predicted the component fit within one size in 94% (r2=0.68) and 96% (r2=0.73) of femoral and tibial components. Cases beyond ±1 sizes did not have notable device-specific adverse events with Kaplan-Meier survivorship of 100% at five years.
Conclusion: Demographic models are an effective tool in component size prediction prior to TKA. This model has implications in reducing the need for preoperative radiographic templating, potentially resulting in increasing surgeon efficiency and possibly reducing hospital implant inventory. This may be particularly important for ambulatory or outpatient surgery centers.
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Surgical Treatment of Sacral Chordoma: En Bloc Resection with Negative Margins is a Determinant of the Long-Term Outcome
Simone Colangeli, MD, Surgeon, Antonio D’Arienzo, MD, Surgeon, Francesco Rosario Campo, MD, Surgeon, Rodolfo Capanna, MD, Director, Department of Orthopedic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, Francesco Muratori, MD, Surgeon, Leonardo Bettini, MD, Resident, Filippo Frenos, MD, Surgeon, Francesca Totti, MD, Resident, Guido Scoccianti, MD, Surgeon, Giovanni Beltrami, MD, Surgeon, Domenico Andrea Campanacci, MD, Director, Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
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Study Design: Retrospective case series.
Objective: To report the outcome of a series of patients with sacral chordoma who were surgically treated at a single center.
Summary: Chordomas are low-grade malignant tumors that arise from remnants of the notochord. They are most often found in the sacrum, spine and skull-base. These tumors have a slow clinical evolution and may eventually metastasize, even after adequate treatment. Rarely, they can dedifferentiate into high-grade sarcomas. Traditionally, chordomas were considered to be resistant to chemotherapy and standard radiation therapy. However, recently, adrotherapy has been shown to be effective for local and systemic control of the disease. In this study, clinical outcomes and local and systemic recurrence were reviewed to identify prognostic factors for local and systemic control.
Methods: Thirty-three patients with sacral chordoma (19 males, 14 females; median age 61 y, range 43-80) who were surgically treated at our institution between 1994 and 2015 were reviewed. In 24 patients, resection was performed above S2. No patients received pre-operative radiotherapy (RT). Three cases received RT (carbon ion therapy) as treatment for local recurrence. Wide (R0) surgical margins were achieved in 17 patients, marginal (R1) margins in 14 patients and intralesional (R2) margins in 2 patients.
Results: At a median follow-up of 53 months (range 0-198), 19 patients were continuously disease-free, 6 were disease-free after local recurrence (5) or metastases (1), 3 were alive with disease (2 local recurrence and 1 metastasis), 4 were dead of disease (1 patient died intraoperatively) and 1 was dead of another cause. Local recurrence was observed in 9 cases (27%); all 9 were treated surgically and 3 received carbon ion therapy after surgical intralesional excision. Overall survival at 10 years was 86.6%. Local recurrence-free survival at 10 years was 51%. A statistical analysis confirmed the importance of negative surgical margins (R0) to achieve local control of the disease (p = 0.0007). High resections (above S2) were associated with lower survival and higher risk of local recurrence.
Conclusion: Surgical en bloc resection is the primary treatment for sacral chordoma. Carbon ion therapy is used when it is difficult to obtain wide surgical margins. Due to morbidity and the disabling sequelae of surgery, adrotherapy may be considered an alternative to high (above S2-S3) sacral chordoma resections.
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Early Experience with a Short, Tapered Titanium Porous Plasma Sprayed Stem with Updated Design
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, Antonio G. Manocchio, Jr., DO, Fellow, Joint Implant Surgeons, Inc., New Albany, Ohio, Associate, Orthopedic Surgeons of Southwest Ohio, Dayton, 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
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Introduction: Short stem femoral components in primary total hip arthroplasty (THA) have increased in popularity since the advent of minimally invasive surgical techniques. The concept of a short stem is particularly compatible with tapered designs where the goal is to offload forces proximally in the femur. The purpose of this retrospective review was to review our early experience with a short, tapered titanium femoral component with updated design features.br /> Materials and Methods: Beginning in November 2011 through February 2012, 92 consented patients (93 hips), at a single center, were treated with primary cementless THA using a short stem, tapered femoral component (Taperloc® Complete Microplasty; Zimmer Biomet, Warsaw, Indiana) and were available for review with a minimum two-year follow-up. Mean patient age at surgery was 63.2 years and body mass index (BMI) was 30.8 kg/m2. Mean stem length used was 110.3mm (range, 95–125). br /> Results: Mean follow-up was 4.5 years (2–6). Harris hip scores improved from 52.5 preoperatively to 84.7 at most recent. One stem was revised the same day for periprosthetic fracture. One patient with early infection was treated with single-stage exchange followed by recurrence that was treated successfully with two-stage exchange. A non-healing wound in one patient was treated with incision and debridement. Radiographic assessment demonstrated no evidence of loosening, osteolysis, distal hypertrophy, or pedestal formation in any hip, and all components appeared well fixed and in appropriate alignment. br /> Conclusion: In this series of patients treated with primary THA using a short, tapered titanium porous plasma-sprayed femoral component with updated design features, good results were achieved with a low incidence of complications and revision. No aseptic loosening or osteolysis has occurred. Radiographic assessment was excellent for all patients.
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Articulating Spacers as a Modified One-Stage Revision Total Knee Arthroplasty: A Preliminary Analysis
Ahmed Siddiqi, DO, Resident, Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Nicole E. George, DO, Research Fellow, Bartlomiej W. Szczech, MD, Clinical Fellow, Jennifer I. Etcheson, MD, MS, Research Fellow, Chukwuweike U. Gwam, MD, Research Fellow, Alexander T. Caughran, MD, Clinical Fellow, Ronald E. Delanois, MD, Director, James Nace, DO, MPT, Fellowship Director/Academic Director, Hip, Knee, and Shoulder Surgery, Rubin Institute Adult Hip and Knee Reconstruction Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Peter B. White, BA, Research Assistant, Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, John V. Thompson, DO, Resident, Department of Orthopaedic Surgery, Wellspan York Hospital, York, Pennsylvania
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Introduction: Periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) is a challenging complication for surgeons and patients alike. Although two-stage revision arthroplasty remains the gold standard PJI management in the United States, one-stage revision has had success in many parts of Europe. The aim of this study was to retrospectively review: 1) ultimate treatment success; 2) necessary antibiotic duration; 3) change in knee range of motion (ROM); and 4) final Knee Society Scores (KSS) in a case series of patients managed with retention of articulating antibiotic spacers following PJI.
Materials and Methods: A retrospective review was performed on all patients treated for chronic PJI after primary TKA with retention of articulating antibiotic spacers at a minimum of one-year follow-up. Descriptive analysis was utilized to evaluate demographic characteristics, discharge destination, follow-up and antibiotic durations, Knee Society Score (KSS), and rates of treatment failure. Paired-Samples t-Tests were utilized to evaluate mean changes in flexion and extension between the preoperative and postoperative time periods.
Results: Our final cohort included 29 patients who were managed with articulating spacer retention at a mean follow-up of 16.8 (range, 12.0 to 23.1) months, with 21 patients (72.4%) medically unfit for multiple surgeons and eight patients (27.6%) satisfied with their function. Mean age was 61.3 (range, 41 to 85) years and mean Charlson Comorbidity Index (CCI) was 6.1 (mean, 0 to 12). The predominant infecting organism was Methicillin-Resistant Staphylococcus aureus (MRSA), which was involved in eight patients (27.6%). There was a significant increase in postoperative knee flexion (+14.7°; p=0.001) and no decrease in postoperative knee extension (+2.3°; p=0.361). Treatment success in our cohort was 79.3% (23 patients), with four patients (13.8%) having chronic wound drainage and two patients (6.9%) requiring multiple spacer exchanges. Sixteen patients (55.2%) were able to complete their antibiotic regimen, with the remaining patients unable to discontinue their antibiotics by latest clinic follow-up.
Discussion: One-stage exchange arthroplasty offers the advantage of a single procedure with analogous failure rates compared to two-stage exchange, decreases hospitalization, and improves cost-effectiveness, which is paramount in today’s healthcare environment. To our knowledge, this is the first study in the United States to evaluate outcome scores, function, and success rate of a modified one-stage revision TKA technique. Although we are unable to make definitive conclusions based on the small sample size, the outcomes in this study are encouraging.
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Cost Analysis of All-Polyethylene Compared to Metal-Backed Implants in Total Knee Arthroplasty
Karim Sabeh, MD, Orthopaedic Surgery Chief Resident, Milad Alam, MD, Orthopaedic Surgery Resident, Samuel Rosas, MD, Orthopaedic Surgery Resident, Shahrose Hussain, BS, Medical Student, Michaela Schneiderbauer, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery and Rehabilitation, The University of Miami Miller School of Medicine, Miami, Florida
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Introduction: The growing trends of total knee arthroplasty (TKA) foreshadow an inevitable increase in the financial burden on healthcare expenditure estimated to almost nine billion dollars annually. This study aims to demonstrate the potential savings when using all-polyethylene (AP) compared to metal-backed (MB) tibial components and describes the cost variability amongst three major commercially available implants.
Materials and Methods: The cost of AP versus MB implants was analyzed using a large nationwide database, Emergency Care Research Institute (ECRI). Cost of femoral components and patellar buttons were excluded. The three manufacturers included in the study were DePuy, Smith&Nephew, and Stryker (Zimmer data was not available for analysis).
Results: Our results show that AP components were significantly less costly in comparison to other manufacturers, and the average AP price was $1,009. The average MB (baseplate plus liner) price was $2,054 (p=0.01). Analysis of variance (ANOVA) of the means of the AP components showed no significant difference in prices among the three studied manufacturers (p=0.946).
Discussion: Our results demonstrate that, regardless of the manufacturing company, AP tibial components are significantly cheaper than their MB counterparts. A literature review revealed that, when indicated, AP implants are not inferior to MB in terms of survivorship or outcome. The average savings was more than $1,000 per TKA when multiplied even by a small portion of the large volume of TKAs completed annually. This can translate into millions of dollars in savings in healthcare expenditures. With the impending legislation of the bundled-payment initiative, orthopaedic surgeons should be aware of less costly implant options that can positively impact outcomes and/or quality of care.
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Complex Fibular Head Avulsion Fracture: Surgical Management of a Case
Vittorio Mattugini, MD, Specialist in Orthopedics and Traumatology, Carmine Citarelli, MD, Resident in Orthopedics and Traumatology, Fabio Cosseddu, MD, Resident in Orthopedics and Traumatology, Marco Ghilardi, MD, Specialist in Orthopedics and Traumatology, Guido Luppichini, MD, Specialist in Orthopedics and Traumatology, Francesco Casella, MD, Specialist in Orthopedics and Traumatology, Giulio Agostini, MD, Resident in Orthopedics and Traumatology, Federico Sacchetti, MD, Resident in Orthopedics and Traumatology, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
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Fibular head avulsion fractures are rare injuries determined by traction of the fibular attachment of the lateral collateral ligament (LCL). Surgical treatment is often recommended with different techniques such as tension band fixation or lag screws stabilization. In this article, we describe a fixation technique of fibular head fractures obtained through the use of anchors. A 45-year-old athletic patient came to our attention in our traumatologic service after a motorcycle accident. He reported a complex injury of the posterolateral corner with an avulsion fracture of the left fibular head. We performed a clinical evaluation at the final follow-up visit (six months). We demonstrated that the use of suture anchors may be an effective technique of fixation in avulsion fracture of the fibular head associated with combined posterolateral corner injuries.
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Perioperative Outcomes and Short-Term Complications Following Total Knee Arthroplasty in Chronically Immunosuppressed Patients
Gannon L. Curtis, MD, Research Fellow, Morad Chughtai, MD, Resident, PGY-1, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Carlos A. Higuera, MD, Vice Chair for Quality and Patient Safety, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Wael K. Barsoum, MD, President, Department of Orthopaedic Surgery, Cleveland Clinic, Weston, Florida, Jared M. Newman, MD, Research Fellow, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
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Background: Although there are studies regarding immunosuppressed patients undergoing total knee arthroplasty (TKA) for inflammatory arthritis or osteonecrosis, there is a paucity of studies evaluating immunosuppressed patients undergoing TKA for diagnoses other than these.
Materials and Methods: We identified all patients undergoing primary TKA for osteoarthritis from 2008–2014 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Overall, 111,624 patients were included. The immunosuppressed group consisted of 3,466 patients, and the control group included 108,158. Outcomes measured included operative time, lengths-of-stay, discharge destination, and 30-day complication rates. Univariate analysis was used to compare the outcomes. Multivariate regression analysis was then applied to determine if immunosuppression was an independent risk factor for differences in outcomes.
Results: Immunosuppressant use did not change operative time, lengths-of-stay, or discharge disposition. Immunosuppressed patients were at higher risks of developing the following surgical and medical complications: organ/space surgical site infection (SSI), wound dehiscence, deep venous thrombosis (DVT), pneumonia, urinary tract infection (UTI), and systemic sepsis. Return to the operating room and 30-day readmission were also significantly higher in the immunosuppressed group.
Conclusions: Patients taking chronic immunosuppressants and undergoing TKA for osteoarthritis are at higher risk of specific surgical and medical complications. These complications include organ/space SSI, wound dehiscence, DVT, pneumonia, UTI, and systemic sepsis. In addition, these patients were at increased odds of returning to the operating room and being readmitted.
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Robotic-Assisted and Computer-Navigated Unicompartmental Knee Arthroplasties: A Systematic Review
Qais Naziri, MD, MBA, Orthopaedic Surgery Resident, Daniel P. Murray, BS, Medical Student, Roby Abraham, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York, Patrick J. Mixa, MD, Orthopaedic Surgery Resident, Bashir A. Zikria, MD, MSc, Associate Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, Akhilesh Sastry, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Portsmouth Regional Hospital, Portsmouth, New Hampshire, Preetesh D. Patel, MD, Director of the Adult Joint Reconstruction Fellowship, Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Introduction: Unicompartmental knee arthroplasty (UKA) effectively improves pain and function associated with isolated compartmental knee arthritis. The developments of computer-navigated and robotic-assisted UKA are among the most significant changes that have improved patient outcomes. This study aimed to systematically review the literature to identify differences between computer-navigated and robotic-assisted UKAs.
Materials and Methods: Twenty total articles were identified. Data pertaining to demographics, outcomes, and complications/failures were extracted from each study. Reoperation/revision rates, indications for reoperation/revision, type of procedure, and number of patients who underwent conversion to TKA (when available) were recorded.
Results: Nine studies reported 451 computer-navigated medial UKAs, with 19 (3.9%) reportedly requiring reoperation: primary revision (n=8; 42.1%), conversion to TKA (n=6), and manipulation under anesthesia (n=5). Eleven studies reported 2,311 robotic-assisted UKAs (74 lateral UKAs), with 106 (5.0%) requiring reoperation: conversion to TKA (n=46; 43.4%), primary revision (n=43), reoperations without component-removal (n=15), subchondroplasty, and partial meniscectomy/synovectomy (both n=1). Reoperation rate discrepancy between computer-navigated and robotic-assisted UKA was not statistically significant (p=0.495); age and BMI differed between both groups (p<0.0001).
Discussion: This study represents the first known comparison of revision rates of computer-navigated and robotic-assisted UKA, suggesting that these methods can benefit orthopaedic surgeons, especially those new to UKA or in a low-volume practice.
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Decreased Time to Return to Work Using Robotic-Assisted Unicompartmental Knee Arthroplasty Compared to Conventional Techniques
Alexander H. Jinnah, MD, Physician Scientist/Resident, Marco A. Augart, MD, Research Fellow, Daniel L. Lara, MD, Research Fellow, Gary G. Poehling, MD, Professor, Johannes F. Plate, MD, PhD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, Riyaz H. Jinnah, MD, FRCS, Professor, Department of Orthopaedic Surgery, Southeastern Regional Medical Center, Lumberton, North Carolina, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Unicompartmental knee arthroplasty (UKA) is a commonly used procedure for patients suffering from debilitating unicompartmental knee arthritis. For UKA recipients, robotic-assisted surgery has served as an aid in improving surgical accuracy and precision. While studies exist detailing outcomes of robotic UKA, to our knowledge, there are no studies assessing time to return to work using robotic-assisted UKA. Thus, the purpose of this study was to prospectively assess the time to return to work and to achieve the level of work activity following robotic-assisted UKA to create recommendations for patients preoperatively. We hypothesized that the return to work time would be shorter for robotic-assisted UKAs compared with TKAs and manual UKAs, due to more accurate ligament balancing and precise implementation of the operative plan.
Materials and Methods: Thirty consecutive patients scheduled to undergo a robotic-assisted UKA at an academic teaching hospital were prospectively enrolled in the study. Inclusion criteria included employment at the time of surgery, with the intent on returning to the same occupation following surgery and having end-stage knee degenerative joint disease (DJD) limited to the medial compartment. Patients were contacted via email, letter, or phone at two, four, six, and 12 weeks following surgery until they returned to work. The Baecke physical activity questionnaire (BQ) was administered to assess patients’ level of activity at work pre- and postoperatively. Statistical analysis was performed using SAS Enterprise Guide (SAS Institute Inc., Cary, North Carolina) and Excel® (Microsoft Corporation, Redmond, Washington). Descriptive statistics were calculated to assess the demographics of the patient population. Boxplots were generated using an Excel® spreadsheet to visualize the BQ scores and a two-tailed t-test was used to assess for differences between pre- and postoperative scores with alpha 0.05.
Results: The mean time to return to work was 6.4 weeks (SD=3.4, range 2–12 weeks), with a median time of six weeks. There was no difference seen in the mean pre- and postoperative BQ scores (2.70 vs. 2.69, respectively; p=0.87).
Conclusion: The findings of the current study suggest that most patients can return to work six weeks following robotic-assisted UKA which appears to be shorter than conventional UKA and TKA. Future level I studies are needed to verify our study findings.
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Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, And Rotation: A Comparative, Gait-Analysis Study
Assem A. Sultan, MD, Clinical Research Fellow, William A. Cantrell, BS, Medical Student, Anton Khlopas, MD, Research Fellow, Inyang Udo-Inyang, Jr., MD, PGY-2 Orthopaedic Surgery Resident, Morad Chughtai, MD, PGY-1 Orthopaedic Surgery Resident, Nipun Sodhi, BA, Research Fellow, Suela Lamaj, BS, Research Volunteer, Nicolas S. Piuzzi, MD, Orthopedic Regenerative Medicine and Cellular Therapy Clinical Scholar, Michael A. Mont, MD, Chairman, PGY-2 Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Roland Starr, MS, Physiotherapist, Anil Bhave, PT, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared.
Materials and Methods: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts.
Results: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66°, [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects.
Conclusion: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.
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Filling Open Screw Holes in the Area of Metaphyseal Comminution Does Not Affect Fatigue Life of the Synthes Variable Angle Distal Femoral Locking Plate in the AO/OTA 33-A3 Fracture Model
Luis Grau, MD, Chief Resident, Kevin Collon, BS, Medical Student, Ali Alhandi, MD, Resident, Fernando Vilella, MD, Assistant Professor, Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, David Kaimrajh, MS, Engineering Department, Loren Latta, PhD, Chief Engineer, Engineering Department, Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, Miami, Florida, Maria Varon, BS, Graduate Student, Department of Biomedical Sciences, Barry University, Miami Shores, Florida
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Introduction: The aim of this study is to evaluate the biomechanical effect of filling locking variable angle (VA) screw holes at the area of metaphyseal fracture comminution in a Sawbones® (Sawbones USA, Vashon, Washington) model (AO/OTA 33A-3 fracture) using a Synthes VA locking compression plate (LCP) (Depuy Synthes, Warsaw, Indiana).
Materials and Methods: Seven Sawbones® femur models had a Synthes VA-LCP placed as indicated by the manufacturers technique. A 4cm osteotomy was then created to simulate an AO/OTA 33-A3 femoral fracture pattern with metaphyseal comminution. The control group consisted of four constructs in which the open screw holes at the area of comminution were left unfilled; the experimental group consisted of three constructs in which the VA screw holes were filled with locking screws. One of the control constructs was statically loaded to failure at a rate of 5mm/min. A value equal to 75% of the ultimate load to failure was used as the loading force for fatigue testing of 250,000 cycles at 3Hz. Cycles to failure was recorded for each construct and averages were compared between groups.
Results: The average number of cycles to failure in the control and experimental groups were 37524±8187 and 43304±23835, respectively (p=0.72). No significant difference was observed with respect to cycles to failure or mechanism of failure between groups. In all constructs in both the control and experimental groups, plate failure reproducibly occurred with cracks through the variable angle holes in the area of bridged comminution.
Conclusions: The Synthes VA-LCP in a simulated AO/OTA 33-A3 comminuted metaphyseal femoral fracture fails in a reproducible manner at the area of comminution through the “honeycomb” VA screw holes. Filling open VA screw holes at the site of comminution with locking screws does not increase fatigue life of the Synthes VA-LCP in a simulated AO/OTA 33-A3 distal femoral fracture. Further studies are necessary to determine whether use of this particular plate is contraindicated when bridging distal femoral fractures with metaphyseal comminution.
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The Role of Virtual Rehabilitation in Total Knee and Hip Arthroplasty
Morad Chughtai, MD, Resident, PGY-1, Assem A. Sultan, MD, Clinical Research Fellow, Anton Khlopas, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Coordinator, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, Sergio M. Navarro, BS, Medical Student, Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, Anil Bhave, PT, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Virtual rehabilitation therapies have been developed to focus on improving care for those suffering from various musculoskeletal disorders. There has been evidence suggesting that real-time virtual rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these conditions. This study specifically evaluated the use of a virtual physical therapy/rehabilitation platform for use during the postoperative period after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of this technology has the potential benefits that allow for patient adherence, cost reductions, and coordination of care.
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Postoperative Pain and Analgesia: Is There a Genetic Basis to the Opioid Crisis?
Randa K. Elmallah, MD, PGY-2 Orthopaedic Resident, University of Mississippi, Department of Orthopaedic Surgery, Jackson, Mississippi, Prem N. Ramkumar, MD, MBA, PGY-2 Orthopaedic Resident, Anton Khlopas, MD, Clinical Research Fellow, Rathika R. Ramkumar, MD, Urology Resident, Morad Chughtai, MD, PGY-1 Orthopaedic Resident, Nipun Sodhi, BA, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Michael A. Mont, MD, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
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Background: Multiple factors have been implicated in determining why certain patients have increased postoperative pain, with the potential to develop chronic pain. The purpose of this study was to: 1) identify and describe genes that affect postoperative pain perception and control; 2) address modifiable risk factors that result in epigenetic altered responses to pain; and 3) characterize differences in pain sensitivity and thresholds between opioid-naïve and opioid-dependent patients.
Materials and Methods: Three electronic databases were used to conduct the literature search: Pubmed, EBSCO host, and SCOPUS. A total of 372 abstracts were reviewed, of which 46 studies were deemed relevant and are included in this review.
Results: Specific gene alterations that were shown to affect postoperative pain control included single nucleotide polymorphisms in the mu, kappa, and delta opioid receptors, ion channel genes, cytotoxic T-cells, glutamate receptors and cytokine genes, among others. Alcoholism, obesity, and smoking were all linked with genetic polymorphisms that altered pain sensitivity. Opioid abuse was found to be associated with a poorer response to analgesics postoperatively, as well as a risk for prescription overdose.
Conclusion: Although pain perception has multiple complex influences, the greatest variability seen in response to opioids among postoperative patients known to date can be traced to genetic differences in opioid metabolism. Further study is needed to determine the clinical significance of these genetic associations.
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Stryker Orthopaedic Modeling and Analytics (SOMA): A Review
Walter Schmidt, MSc, Senior Manager, Modeling & Simulation Department, Sally LiArno, PhD, Senior Staff Engineer, Andreas Petersik, PhD, Doctor of Engineering, Stryker Orthopaedics, Mahwah, New Jersey, Anton Khlopas, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Due to the differences in bone morphology between demographics such as age, gender, body mass index, and ethnicity, the development of orthopaedic implants requires a large number of anatomical data from various patient populations. In an effort to assess these demographic variations, Stryker Orthopaedic Modeling and Analytics (SOMA) has been developed. SOMA is a suite of tools which utilizes a comprehensive database of computed tomography scans (CT-scans), plus associated three-dimensional (3D) bone models, allowing the user to assess population differences in bone morphology, bone density, and implant fit for the purposes of research and development. Several additional software tools are currently in development to further analyze bone density and have the potential to enhance component fit. These tools, in combination with the database, have been previously utilized for development of many implant designs and techniques in hip and knee arthroplasty, as well as in trauma surgery.
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A Comparative Effectiveness Study for Non-Operative Treatment Methods for Knee Osteoarthritis
Frank R. Kolisek, MD, Hip and Knee Surgeon, Charles Jaggard, MS, Clinical Trial Manager, Department of Orthopaedic Surgery, OrthoIndy Hospital, Greenwood, Indiana, Anton Khlopas, MD, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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A number of non-operative treatment options are commonly prescribed for patients presenting with degenerative osteoarthritis of the knee, where surgery is not yet recommended. However, there is a paucity of studies evaluating the comparative effectiveness of these treatment options to best inform both patients and providers. This study examined the comparative effectiveness of a home exercise program versus bracing or a combination of the two (brace-only, exercise-only, and brace and exercise cohorts) on the following: 1) objective functional measures (quadriceps muscle strength, Self-Paced Walk Test [SPWT], and Timed “Up & Go” [TUG] Test); 2) subjective functional measures (Lower Extremity Function Scale [LEFS] and Health Survey [VR-12] outcomes); 3) pain using Visual Analog Scale [VAS-10]; 4) patient metrics (patient treatment preference, perceptions, and compliance); and 5) progression to total knee arthroplasty (TKA) over a 12-week period. Subjects exhibited significant improvements from baseline on all measures regardless of group assignment; however, the only significant difference between groups was the larger improvement in pain scores between the brace-only and the exercise-only cohorts (p = 0.022). The brace-only regimen may be more efficacious; however, larger studies are needed to confirm this. These findings suggest that patients who are provided with either treatment option may be able to achieve a better quality of life and return to activity that may delay an elective joint arthroplasty surgery.
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Ten-Year Clinical and Radiological Outcomes of 100 Total Hip Arthroplasty Cases with a Modern Cementless Dual Mobility Cup
Loïc Laurendon, MD, Doctor of Surgery, Service de chirurgie orthopédique, Hopital Nord, CHU Saint Etienne, France,, Rémi Philippot, MD, PhD, Professor of Surgery, Thomas Neri, MD, PhD, Doctor of Surgery, Bertrand Boyer, MD, PhD, Doctor of Surgery, Service de chirurgie orthopédique, Frédéric Farizon, MD, Professor of Surgery, Service de chirurgie orthopédique, Hopital Nord, CHU Saint Etienne, and Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM), Université Claude Bernard Lyon 1, Université Jean Monnet Saint Etienne, France
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Introduction: The original cementless Sunfit® dual mobility cup (SERF, Décines, France) exhibited limited osseointegration due to its hydroxyapatite and alumina coating. We hypothesized that replacement of the alumina with plasma-sprayed titanium + hydroxyapatite and improvement of the external geometry (Sunfit TH®) would not increase the risk of aseptic loosening. The primary goal of this study was to determine the survivorship and clinical and radiological outcomes among patients with the Sunfit TH® implant.
Material and methods: This was a single-center, prospective study of the first 100 consecutive total hip arthroplasty (THA) cases performed using the combination of a press-fit Sunfit TH® dual mobility cup and a cementless straight stem. All of the cases were primary THA and the posterolateral approach was used. The patients underwent regular clinical and radiological monitoring. Radiological measurements were carried out using OsiriX® software (Pixmeo, Geneva, Switzerland).
Results: As of the final follow-up, 19 patients had died and 4 could not be contacted. Of the remaining patients, there were zero cases of aseptic loosening, dislocation or intraprosthetic dislocation (IPD). The survivorship was 100% at 10.03 years of follow-up. No significant implant migration was measured on radiographs.
Conclusion: The excellent long-term outcomes with the Sunfit TH® cup are likely due to the use of plasma-sprayed titanium + hydroxyapatite in the coating and the addition of supplementary ridges and grooves to the outside of the cup. The absence of aseptic loosening, dislocation and IPD further confirms the high stability and good survivorship that can be achieved with these implants. We believe dual mobility cups should be used in patients above 60 years of age and in those below 60 years of age with a high risk of postoperative instability.
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All-Inside Technique for ACL-Reconstruction using a FlipCutter® and the TightRope® System
Nicos Papaloucas, MD, Consultant Orthopedic Surgeon, Orthopedic Department, Aretaeio Hospital, Nicosia, Cyprus
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There have been many innovations in the field of ACL-reconstruction over the years, including the FlipCutter® and TightRope® system (both from Arthrex Inc.). The FlipCutter® is a combined guide pin and reamer that allows minimally invasive socket-creation from the inside out, especially in difficult-to-reach areas. The TightRope® is a further development of the well-known Endobutton™ (Smith & Nephew plc) that consists of a four-point knotless locking system. Its main advantage is its adjustability, which makes it possible to fill the entire bone socket with the graft without any empty space.
The all-inside technique using a FlipCutter® and TightRope® offers several advantages:
1. No additional accessory portals and no hyperflexion of the knee are necessary during creation of the femoral canal. Using the FlipCutter®, which is a “retro drill,” an outside-in technique is applied. This avoids the problems that arise when using the anteromedial portal for creation of the femoral canal.
2. The thickness of the femoral wall can be accurately measured before drilling.
3. There is no empty space in the femoral canal.
4. Only one tendon is needed. Usually only the semitendinosus tendon is used.
5. There is no need for a tibial canal through the cortex.
The procedure starts with diagnostic knee arthroscopy to confirm the ACL-tear and to address any possible additional meniscal or cartilaginous lesions. Graft harvest and preparation (usually only the semitendinosus tendon is needed) is then performed. Next, the knee is prepared by creation of a femoral canal: after the entry point of the femoral canal is localized, while viewing through the medial portal with the knee held at 90° of flexion, the femoral canal is created using the appropriate femoral guide and a FlipCutter®. The tibial canal is then created using the tibial guide and a FlipCutter®. Finally, the graft is passed through the medial portal to the femoral socket and stabilized with the TightRope®. The tibial end is passed through the tibial canal and stabilized with a TightRope® ABS Button.
In summary, this all inside technique for ACL- Reconstruction using FlipCutter® and TightRope® offers several advantages over traditional techniques, including no need for hyperflexion or an additional accessory medial portal while creating the femoral socket, accurate measurement of the whole thickness of the femoral condyle before drilling, the possibility of minor changes according to the desired femoral canal length, the ability to achieve no empty space in the femoral canal between the graft and bony canal, and the need for only one tendon (semitendinosus). Additionally, with this technique, the surgeon can easily place isometric sockets in the femur and tibia.
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Biological Intercalary Reconstruction with Bone Grafts After Joint-Sparing Resection of the Lower Limb: Is this an Effective and Durable Solution for Joint Preservation?
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Francesca Totti, MD, Resident, Maurizio Scorianz, MD, Specialist in Orthopedics and Traumatology, Guido Scoccianti, MD, Specialist in Orthopedics and Traumatology, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, Department of Orthopaedic Oncology and, Reconstructive Surgery, University of Florence, Azienda Ospedaliera, Universitaria Careggi, Florence, Italy, Antonio D’Arienzo, MD, Specialist in Orthopedics and Traumatology, Francesco Rosario Campo, MD, Specialist in Orthopedics and Traumatology, Carmine Citarelli, MD, Specialist in Orthopedics and Traumatology, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and, Traumatology, Pisa, Italy, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Department of Pediatric Orthopaedic Oncology, University of Florence, Azienda Ospedaliera, Universitaria Careggi, Florence, Italy
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Due to advances in neoadjuvant therapies and preoperative imaging modalities, joint-sparing resections have become appealing in bone tumor surgery. However, the intercalary reconstruction of metadiaphyseal bone defects of the femur and the tibia after juxta-articular tumor resection remains challenging. Both biological and prosthetic reconstructions have been used for joint-sparing resections, but little is known about the long-term outcome of these procedures.
The authors reviewed a consecutive series of 64 patients treated with joint-sparing intercalary resection and reconstruction with bone grafts. Inclusion criteria were an osteotomy line within 5 cm from the knee and ankle joint surface and an osteotomy line proximal to 1 cm below the lesser trochanter at the hip level. Intra-epiphyseal resection was performed in 25 patients (39%)and intercalary resection was performed in 39 (61%). Reconstruction included 49 allograft + vascularized fibular graft (VFG), 10 allografts, and 5 VFG + structural allogenic grafts. At a mean follow-up of 117 months (range 12-305), 51 patients (80%) were continuously disease-free, and 6 showed no evidence of disease after treatment of local recurrence or metastatic lesion. One patient was alive with lung metastases at 26 months of follow-up and six patients died of disease.
In the entire series of 64 patients, 26 had a non-oncological complication that required surgical revision (40.6%). Overall survival (OS) of reconstruction was 92% at 5 years and 90% at 10 and 15 years. Limb salvage survival (LSS) was 94% at 5, 10 and 15 years.
Twenty-two fractures occurred in 17 patients (26.5%). There were a total of nine non-unions (14%). Six patients (9.3%) presented early wound dehiscence (average 1.8 months, range 0-6). A deep infection occurred in 3 cases (4.7 %).
In 12 patients treated with VGF reconstruction (12/54:22%), a donor-site complication was observed. The overall Musculoskeletal Tumor Society (MSTS) functional score in 54 evaluable patients, who were alive with reconstruction in situ, was 27 points (range 18-30).
Biologic intercalary reconstructions with bone grafts resulted in effective joint-sparing resections of the lower limb, allowing joint preservation in all but one case who required a total knee replacement for varus osteoarthritis. Despite the high rate of complications requiring surgical revision, at 15 years, overall survival of the reconstruction was 90% and limb salvage survival was 94%. In our experience, revision-free survival was better with VFG reconstruction than with allograft alone and the combination of VFG and allogenic graft seems to favor spontaneous fracture-healing and to decrease the non-union rate.
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Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty
Chukwuweike U. Gwam, MD, Research Fellow, Tanner McGinnis, BS, Research Fellow, Jennifer I. Etcheson, MS, MD, Research Fellow, Nicole E. George, DO, Research Fellow, Anil Bhave, PT, Director of Physical Therapy, Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, Steven F. Harwin, M.D, Chief, Adult joints reconstruction, Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland, Assem A. Sultan, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Introduction: Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM).
Materials and Methods: This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed.
Results: Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001).
Conclusion: This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.
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Sub-Trochanteric Hip Fracture Following Core Decompression for Osteonecrosis in a Patient with a Pre-Existing Contralateral Occult Femoral Neck Fracture
Ryan J. Berger, MD, Orthopaedic Surgery Resident, Connor Cole, PA, Physician Assistant, Nipun Sodhi, BA, Clinical Research Fellow, Anton Khlopas, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Assem A. Sultan, MD, Clinical Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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We present a unique case of a 62-year-old patient with bilateral osteonecrosis of the femoral heads secondary to corticosteroid use. She presented with an occult right femoral neck fracture and was treated with percutaneous pinning of the right femoral neck and a left-sided percutaneous drilling. Despite apparent appropriate technique, the patient sustained a left sub-trochanteric hip fracture while shifting in bed in the postoperative care unit and was taken back for cephalo-medullary nail fixation. Femoral head osteonecrosis may be an under-reported risk factor for development of pathological neck fractures. We present an overview of this topic along with suggestions for joint preservation treatment of similar patients at higher risk for perioperative fracture.
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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, Scott R. Small, MS, Engineering Director, Joint Replacement Surgeons of Indiana Foundation, Mooresville, Indiana, Jeffrey B Elliott, MS, Grace E. Gibbs, BS, Ryan B. Seale, MS, Rose-Hulman Institute of Technology, Terre Haute, Indiana, Merrill A. Ritter, MD, Executive Director, Joint Replacement Surgeons of Indiana Foundation, Mooresville, Indiana
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.
31/873
27-06-2017
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Does Atrial Septal Defect Increase the Risk of Stroke Following Total Hip and Knee Arthroplasty?
Morad Chughtai, MD, Resident, PGY-1, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Jared M. Newman, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Dean Perfetti, MD, Research Fellow, Aditya V Maheshwari, MD, Orthopaedic Attending, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, Chukwuweike U. Gwam, MD, Research Fellow, Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
Introduction: Atrial septal defect (ASD) is a common asymptomatic congenital heart condition that predisposes patients to paradoxical emboli in the cerebral vasculature. In this study, we evaluated the prevalence of ASD and risk of stroke for patients with ASD undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).
Materials and Methods: We used the New York Statewide Planning and Research Cooperative System to identify 258,911 elective primary THA/TKA between 2005 and 2014, including 140 patients with ASD. Logistic regression models calculated odds ratios (OR) and 95% confidence intervals (CI) and controlled for demographic and medical risk factors for stroke.
Results: The prevalence of ASD was 54 per 100,000 patients undergoing THA/TKA. The rate of stroke within 30 days of surgery was 5.7% (95% CI: 2.5%, 11.0%) for patients with ASD, and 0.1% (95% CI: 0.1%, 0.1%) for all other patients. In regression models, the risk of stroke was 70 times greater (OR: 70.0, 95% CI: 32.9, 148.9) for patients with ASD compared to patients without this condition (p<0.001).
Conclusions: Patients with ASD undergoing THA and TKA are predisposed to stroke in the postoperative period. Orthopaedic surgeons indicating patients for surgery and internists performing preoperative medical clearance should be aware of these risks and discuss them prior to surgery. The efficacy of pharmacological and surgical measures to reduce postoperative stroke within this patient population should be topics of future investigation.
31/868
4-09-2017
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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, Johannes F. Plate, MD, PhD, Resident, Physician Scientist, Maxwell K. Langfitt, MD, Assistant Professor, John S. Shields, 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
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.
31/881
15-07-2017
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Social Media and Pediatric Scoliosis: An Analysis of Patient and Surgeon Use
Heather S. Haeberle, BS, Sergio M. Navarro, BS, Mary M. Cornaghie, BA, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, Anthony C. Egger, MD, Resident, Prem N. Ramkumar, MD, MBA, Resident, Ryan C. Goodwin, MD, Orthopaedic Surgeon, Michael A. Mont, MD, Chairman, Department of Orthopaedics, Cleveland Clinic, Cleveland, Ohio
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.
31/877
15-06-2017
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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, 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
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.
31/880
29-08-2017
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Does Obesity affect Outcomes in Patients Undergoing Innovative Multi-modal Physical Therapy Following Primary Total Knee Arthroplasty?
Nirav K. Patel, MD, Clinical Fellow, Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, Morad Chughtai, MD, Resident, PGY-1, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Assem A. Sultan, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike Gwam, MD, Research Fellow, Tanner McGinn, BS, Research Assistant, Anil Bhave, MS, Director of Physical Therapy, Jaydev B. Mistry, MD, Research Fellow, 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
Introduction: Knee stiffness following total knee arthroplasty (TKA) is a common complication, especially in obese patients. The initial, non-operative treatments for this complication includes splinting and physical therapy. If these measures fail, manipulation under anesthesia (MUA) or surgical exploration can be considered to restore range of motion (ROM). However, it is generally desirable to avoid these procedures. For these reasons, newer physical therapy protocols have been developed. However, it is unknown whether these protocols are efficacious for obese patients. Therefore, the purpose of this study was to evaluate and compare: 1) ROM; 2) the rate of MUA; 3) number of physical therapy visits; and 4) costs in patients who underwent innovative multimodal physical therapy (IMPT) and were either obese or non-obese.
Materials and Methods: A review of a consecutive series of patients undergoing TKA at a single center within a three-year period was performed. All patients received IMPT post-TKA. Patients were divided into obese (body mass index (BMI >30kg/m2) and non-obese (BMI <30 kg/m2) groups. One-hundred and forty-nine patients underwent TKA and had a mean age of 67 years (range, 42 to 88 years). There were 48 patients in the non-obese group and 101 in the obese group. The obese group was significantly younger (mean, 60 years; range 38 to 54 years vs. mean, 69 years; range, 50 to 88 years), with a similar gender distribution. Comparisons of ROM, MUA, number of physical therapy visits, and costs were performed using Student’s t-tests and Chi-square tests as appropriate. Cost-analysis was also performed based on the number of visits to physical therapy (PT).
Results: At latest follow-up, there were no significant differences in mean flexion (mean, 115º, range, 90 to 130º vs. mean, 113º, range 60 to 130º) and extension (mean, 0.81º, range, 0 to 10º vs. 0.54º, range 0 to 10º, p=0.469) between the two groups. The obese group had a 14% (n = 12) rate of MUA compared to 2% (n=1) in the non-obese group (p=0.045). Obese patients had a significantly higher number of mean visits to PT. There was significantly higher mean healthcare costs in the obese (mean, $3,919, range $1,043 to $11,749) as compared to the non-obese (mean, $2,950, range $741 to $7,865) group.
Discussion: Although both cohorts have similar mean ROM at final follow-up, the obese cohort had a significantly higher proportion of patients who underwent MUAs following TKA as compared to non-obese patients, despite IMPT. At latest follow-up, the ROM achieved between the two groups was similar. Obese patients required more PT visits resulting in significantly higher mean healthcare costs.
31/919
15-11-2017
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Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report
Ahmed Siddiqi, DO, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Carl T. Talmo, MD, Associate Professor, James V. Bono, MD, Associate Professor, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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).
31/887
6-07-2017
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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, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Research Fellow, Assem A. Sultan, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Chukwuweike U. Gwam, MD, Research Fellow, Nequesha Mohamed, MD, Research Fellow, Anil Bhave, MS, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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.
31/889
12-07-2017
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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, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Salahuddin Nasir, BS, Benjamin S.T. Yates, BA, 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
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.
31/890
18-07-2017
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Normal Range of Patellar Tendon Elasticity Using the Sharewave Elastography Technique: An In Vivo Study in Normal Volunteers
Alexandre Hardy, MD, Resident, Camille Rodaix, MD, Resident, Raphaël Vialle MD, PhD, Professor/Head of Department, Hospital-University Department for Innovative Therapies in Musculoskeletal Diseases, The MAMUTH-DHU, Armand Trousseau Hospital, Pierre and Marie Curie University, Paris, France, Claudio Vergari, PhD, Biomechanics Engineer, Arts et Métiers, Paristech, Institut de Biomécanique Humaine Georges Charpak, Paris, France
IIn-vivo investigation of tendon mechanical properties in healthy subjects using Shear Wave Elastography (SWE) techniques is a relatively new field of study. This work aims to evaluate the elastic properties of the patellar tendon in various knee range of flexion. Twenty healthy adult subjects were enrolled in the study. Shear wave speed (SWS) in the patellar tendon was measured in three different positions: Knee extended, knee semi-flexed (30°), and knee flexed (90°). Mean shear modulus was 50.9 +- 33.1 kPa in knee extension position, 137.5 +- 50.7 kPa in 30° flexion position, and 226.5 +- 60.3 kPa in 90° flexion position. The lowest shear modulus was obtained at rest with the knee in a fully extended position. These results are in agreement with those previously reported on Achilles tendon and triceps muscles. Shear modulus values obtained in our study could be considered as baseline values for further investigations in adults.
31/893
8-08-2017
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Early Experience with a Tapered Titanium Porous Plasma Sprayed Stem with Updated Design
Antonio G. Manocchio, Jr., DO, Fellow, Associate, Keith R. Berend, MD, Vice President, Chief Executive Officer and President, White Fence Surgical Suites, Michael J. Morris, MD, Partner, 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, The Ohio State University, Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio
Introduction: The Taperloc® Complete femoral stem (Zimmer Biomet, Warsaw, Indiana) builds on the widespread clinical success of the original Taperloc design used since 1982. Enhancements to the Complete design include a lowered caput-collum-diaphyseal (CCD) angle from 138° to 133° for improved offset, optimized neck taper with polished neck flats to increase range of motion, reduced distal geometry to improve proximal canal fill, and gradual off-loading that is the goal of tapered geometry. A retrospective review was conducted to assess our early experience with the updated design.
Materials and Methods: A query of our practice’s arthroplasty registry revealed 97 consented patients (103 hips) who underwent primary cementless THA performed with a Taperloc® Complete femoral component between November 2010 and March 2011. A high offset option, accomplished by a constant 7.8mm medial shift of the trunnion, was utilized in 94 hips (91%). Mean age was 61.8 years and body mass index (BMI) was 31.3 kg/m2. Underlying diagnoses were osteoarthritis in 96 (93%), four avascular necrosis, two post-traumatic arthritis, and one acute fracture.
Results: Mean follow-up was 5.3 years (2–7). Harris hip scores improved from 53.6 preoperatively to 87.9 at most recent. One stem was revised for periprosthetic fracture. Other reoperations were one cup revised for iliopsoas impingement, one lateral femoral cutaneous neurectomy, and one incision and debridement for a non-healing wound. Postoperative radiographs revealed satisfactory position and alignment of components with no radiolucencies observed in all patients with no evidence of osteolysis, distal hypertrophy, or pedestal formation.
Conclusion: In this group, good results with a low frequency of complications and stem revision were achieved with a tapered titanium porous plasma-sprayed femoral component with updated design features. No aseptic loosening or osteolysis occurred. Radiographic findings were excellent in all hips.
31/909
23-08-2017
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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 Scalsky, BS, Research Assistant, Shreya Singh, BS, Research Assistant, 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, Nicolas S. Piuzzi, MD, Clinical Fellow, Cleveland Clinic Foundation, Cleveland, Ohio
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.
31/897
5-08-2017
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Acute Kidney Injury after Total Knee Arthroplasty: A Clinical Review
Ahmed Siddiqi, DO, Resident, Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, Peter B. White, BA, Research Assistant, Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, Jennifer I. Etcheson, MD, MS, Research Fellow, Nicole E. George, DO, Research Fellow, Chukwuweike U. Gwam, MD, Research Fellow, Nirav G. Patel, MD, FRCS, Research Assistant, Hephizibah Adamu, MD, Research Assistant, Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Jaydev B. Mistry, MD, Resident, SUNY Downstate Medical Center, Brooklyn, NY
Introduction: Patients who develop acute kidney injury (AKI) have an increased risk for progression to chronic kidney disease, end-stage renal disease, and increased mortality. The outcomes of total knee arthroplasty (TKA) patients who develop AKI have remained controversial. The purpose of this review was to summarize and identify the current literature focused on 1) major risk factors, 2) short-term outcomes, and 3) costs associated with the development of perioperative AKI after TKA.
Materials and Methods: A literature search was performed using PubMed and Ovid to find literature relevant to AKI in TKA. All abstracts found via literature search were screened for relevancy to the study topics: (1) risk factors, (2) short-term outcomes, and (3) cost.
Results: A total of 447 abstracts were initially identified. Irrelevant abstracts and those not in English were excluded from the study (n=336). Forty-five papers focused on risk factors associated with AKI, six papers focused on short-term outcomes, and seven discussed cost savings. Increased body mass index, metabolic syndrome, perioperative antibiotics, antihypertensive medications, and antibiotic-impregnated cement spacers are amongst the many modifiable patient and drug-induced risk factors associated with AKI after TKA. Perioperative renal injury is associated with increased inpatient and long-term mortality with increased length of stay and extended care facility discharge.
Conclusion: Increased length of stay and comorbidities have shown higher cost utilization and readmission rates. Inpatient and long-term complications and mortality are associated with postoperative AKI and a multidisciplinary perioperative approach is necessary to appropriately identify and, ultimately, prevent patients at higher risk for acute renal failure.
31/898
11-08-2017
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Mechanical Prophylaxis after Lower Extremity Total Joint Arthroplasty: A Review
Morad Chughtai, MD, Resident, PGY-1, Jared M. Newman, MD, Clinical Research Fellow, Iyooh U. Davidson, MD, Resident, Nipun Sodhi, BA, Clinical Research Fellow, Benjamin Gaal, Research Volunteer, Anton Khlopas, MD, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Max Solow, BS, St. George’s University School of Medicine, Grenada, West Indies
Venous thromboembolism (VTE) is a serious complication that can occur after total hip and knee arthroplasty, and can potentially lead to significant morbidity and even mortality. While various modalities have been used to prevent VTE development, the medications can be associated with a number of adverse events. Therefore, mechanical prophylaxis with pumps and compressive devices has been used more frequently alone, or in combination, with medications. Therefore, the purpose of this study was to review the current literature on mechanical prophylaxis for VTEs after lower extremity total joint arthroplasty. Specifically, we reviewed mechanical prophylaxis after: 1) total hip arthroplasty and 2) total knee arthroplasty.
31/900
26-08-2017
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Percutaneous Hallux Valgus Correction: Modified Reverdin-Isham Osteotomy, Preliminary Results
Giuseppe Restuccia, MD, Specialist in Orthopedics and Traumatology, Alessandro Lippi, MD, S.D. Ortopedia e Traumatologia, Maurizio Benifei, MD, Specialist in Orthopedics and Traumatology, S.D. Ortopedia e Traumatologia, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy, Federico Sacchetti, MD, Resident in Orthopedics and Traumatology, Carmine Citarelli, MD, Resident in Orthopedics and Traumatology, Francesco Casella, MD, Specialist in Orthopedics and Traumatology, Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
Background: Hallux valgus (HV) is a metatarsophalangeal joint deformity that can be classified as mild, moderate, or severe. Treatment is recommended for pain or severe deformities. Recently, operative percutaneous correction techniques have been performed to treat mild deformities. Materials and Methods: A retrospective, single-surgeon, single-center study of 49 HV percutaneous correction using a modified Reverdin-Isham osteotomy was conducted. HV, intermetatarsal angle (IM), proximal articular set angles (PASA), and American foot and ankle functional score (AOFAS) were assessed pre- and postoperatively by a single operator. Statistical analysis was performed using a Wilcoxon rank test. Medium time of follow-up was 34 months. Results: HV mean value decreased from a preoperative medium value of 35.18° to 14.3° postoperatively, IM mean value decreased from 15.5° to 8.7°, and PASA from 7.2° to 5.25°(p<0.001 for HV and IM, p<0.125 for PASA reduction). Postoperatively AOFAS medium score was 95. Discussion: In our series, functional and clinical results of percutaneous osteotomy without osteosynthesis were comparable to other percutaneous and conventional techniques, both in clinical and radiological findings. High level of patient’s satisfaction and improvement on pain-related symptoms are even better referred to traditional techniques. Modified Reverdin-Isham osteotomy technique differs from the others for translation of metatarsal head after osteotomy; we do not correct PASA angles, but we can obtain more HV and IM correction and include some severe HV. Our results suggest that translation of metatarsal head could give higher HV angle correction.
31/902
1-09-2017
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Quadriceps and Hamstring Muscle Strength Improves After Unicompartmental Knee Arthroplasty
Jennifer Kurowicki, MD, Research Fellow, Martin Roche, MD, Chief of Orthopaedics, Department of Orthopedic Surgery, 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, Michael A. Mont, MD, Chairman, 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, Peter M. Bonutti, MD, Attending Physician, Bonutti Clinic, Effingham, Illinois
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.
31/901
30-07-2017
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Primary Septic Arthritis of The Knee Due to Mycobacterium Tuberculosis in a Previously Healthy Child
Samuel Rosas, MD, Resident Physician Scientist, Wake Forest School of Medicine, Winston-Salem, North Carolina, Daniel Rosas, BS, Senior Valentina Múnera Orozco, MD, Attending Physician, Manuela Parra Cardona, MD, Attending Physician, Simon Pedro Aristizabal, MD, Attending Orthopaedic Surgeon, Department of Orthopedics, Universidad CES, Medellín, Antioquia, Colombia, Chukwuweike Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
Pediatric septic arthritis can be a devastating disease. Often, the diagnosis can be challenging as autoimmune and infectious causes may present in a similar fashion. Thus, we present the case of a five-year-old male patient, from the Pacific coast of Colombia, with chronic morning knee pain and stiffness thought to be caused by an autoimmune disease. He presented with a mild effusion of the left knee, a flexed posture, and limited extension to 25º. Inflammatory markers demonstrated an infectious pattern. Autoimmune markers were negative. A diagnostic arthrotomy and lavage was conducted followed by microbial cultures, cell count, and gram staining. Polymerase chain reaction (PCR) of the joint fluid demonstrated mycobacterium tuberculosis. The patient was treated according to the national protocols and continued on to complete resolution. Infectious arthritis with m. tuberculosis may present in a chronic indwelling fashion with mildly elevated reactants in immunocompetent, previously healthy children even without any risk factors.
31/905
20-08-2017
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Presentation of Knee Osteoarthritis in the Emergency Department: A Problem Worth Mentioning?
Chukwuweike U. Gwam, MD, Research Fellow, Jennifer I. Etcheson, MD, MS, Research Fellow, Nicole E. George, DO, Research Fellow, Jaydev B. Mistry, MD, Research Fellow, Nequesha Mohamed, MD, Research Assistant, Aamir Patel, MD, Research Assistant, 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, Peace N. Gwam, BA, Research Assistant, University of Maryland, Department of Economics, College Park, Maryland, Nicolas S. Piuzzi, MD, Clinical Fellow, Cleveland Clinic Foundation, Cleveland, Ohio
Introduction: Osteoarthritis (OA) of the knee is a progressive debilitating disease affecting more than 27 million Americans. Treatment is often aimed at reducing pain and slowing disease progression. However, patients with significant barriers to healthcare may elect to visit the emergency department (ED) due to OA-related knee pain. The purpose of this study is to provide a detailed analysis of 1) patient demographics; 2) payor type; 3) charges; and 4) discharge status of patients presenting to the emergency department with a primary diagnosis of knee OA.
Materials and Methods: The Nationwide Emergency Department Sample from 2009 to 2013 was queried for all patients who presented to the ED with a primary diagnosis of knee OA (ICD-9 CM=715.96) and did not have a concomitant major injury. This yielded 215,253 patients. An analysis of variance (ANOVA) test with a post-hoc Turkey-Kramer test was conducted to assess mean differences of continuous data over time. All categorical data was analyzed using chi-square analysis.
Results: The incidence of ED visits dropped significantly between the years 2009 and 2010 (68,661 to 36,846) and plateaued between the years 2010 and 2013. Patients had a mean age of 59.9 years and were primarily women (67.3%). The majority of patients were at the lowest 50% income bracket (68.8%). The Southern US census region had the highest number of ED visits (n=91,995; 42.7%), and Medicare was the primary payor in most cases (n=87,323; 40.7%). The mean charge for ED visits from 2009 to 2013 was $1,368.39, and there was a statistically significant increase in ED-related charges between 2009 and 2013 (p<0.001). The majority of discharges from the ED were routine (n=202,247; 93.8%).
Conclusion: While the early management of knee osteoarthritis is largely successful at delaying the need for surgery, there are still many patients who do not receive adequate care and present to the emergency room for non-emergent evaluation. This, along with rising charges for ED visits, is likely increasing resource consumption and the financial impact on the healthcare system. Future efforts should focus on improving access to care for patients with knee OA before it develops into an overwhelming burden.
31/906
13-09-2017
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National Age and Gender Specific Costs in Anterior Cruciate Ligament Reconstruction by A Single Nationwide Private Payer
Samuel Rosas, MD, Resident Physician Scientist, Jennifer Kurowicki, MD, Orthopaedic Surgery Research Fellow, School of Health and Medical Sciences, Seton Hall University, South Orange, New Jersey, Michael Hughes, MD, Chief Resident, Karim Sabeh, MD, Chief Resident, Jonathan Sheu, Michael Baraga, MD, Associate Professor, Division of Sports Medicine, University of Miami, Miami, Florida
Background: Anterior cruciate ligament tears are an unfortunate, but common, event in the United States, with an estimated 100–300,000 reconstructions performed annually. Limited literature has been published analyzing the reimbursement patterns for the reconstruction of this ligament and, thus, cost-effectiveness studies have relied mainly on data from a limited number of subjects and hospitals.
Purpose: The purpose of this study was to perform an epidemiological cost analysis of anterior cruciate ligament reconstructions and to analyze and describe the reimbursement patterns for this procedure that can be used as reference for future cost-analysis studies. We conducted a retrospective review of a large private payers insurance company records to identify patients who underwent ACL reconstruction (ACLR) between 2007 and 2014.
Materials and Methods: This was achieved through a structured query of the database with the use of current procedural terminology (CPT) codes. Inclusion criteria for this study were patients housed in the insurer database between the ages of 10 and 59. Reimbursements were calculated at the day of surgery and the 90-day global period. Statistical analysis was based on growth and cohort comparison according to demographic. The consumer price index (CPI) of the Bureau of Labor Statistics was used to calculate inflation.
Results: The adjusted mean same-day costs were $11,462 (standard deviations [SD] of $869) for female patients and $12,071 (SD of 561) for males (p=0.07), with no significant difference among same-day costs in either females (p=0.023 for ages 10 to 34 and p=0.037 for ages 35 to 59) or males (p=0.46 for ages 10 to 34 and p=0.26 for ages 35 to 59). The adjusted mean 90-day costs were $14,569 (SD of $835) for females and $14,916 (SD of $780) for males, with no significant difference among 90-day costs in either females (p=0.229 for ages 10 to 34 and p= 0.386 for ages 35 to 39) or males (p=0.425 for ages 10 to 34 and p=0.637 for ages 35 to 39). A matched-age cost analysis demonstrated that gender did not play a significant role in costs (p<0.01 for all groups).
Conclusion: In the setting of arthroscopic ACLR, both same-day and 90-day costs do not significantly differ between age-matched males and females.
31/912
10-09-2017
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No Evidence of Increased Infection Risk with Forced-Air Warming Devices: A Systematic Review
Heather S. Haeberle, BS, Sergio M. Navarro, BS, Baylor College of Medicine, Houston, Texas, Linsen T. Samuel, MD, MBA, Clinical Research Fellow, Anton Khlopas, MD, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Morad Chughtai, MD, PGY-1 Orthopaedic Surgery Resident, Michael A. Mont, MD, Chairman, Prem N. Ramkumar, MD, MBA, PGY-2 Orthopaedic Surgery Resident, Cleveland Clinic, Cleveland, Ohio
Introduction: Forced-air warming devices have been reported to present a potential risk for surgical site infections (SSIs) and periprosthetic joint infections. Due to a lack of consensus, we reviewed the infection risk of forced-air warming devices.
Materials and Methods: A systematic literature review was performed, evaluating overall infection risk and bacterial load. A total of eight studies reporting outcomes from 1,965 subjects were included.
Results and Conclusions: There is no current evidence in the orthopaedic literature that forced-air warming devices translate to increased SSIs. Accordingly, these devices should continue to be used for the maintenance of intraoperative normothermia.
31/952
9-11-2017
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A Case for the Brace: A Critical, Comprehensive, and Up-To-Date Review of Static Progressive Stretch, Dynamic, and Turnbuckle Braces for the Management of Elbow, Knee, and Shoulder Pathology
Nipun Sodhi, BA, Research Fellow, Benjamin Yao, BA, Anton Khlopas, MD, Research Fellow, Iyooh U. Davidson, MD, Resident, Assem A. Sultan, MD, Research Fellow, Linsen T. Samuel, MD, MBA, Research Fellow, Suela Lamaj, BS, Research Volunteer, Benjamin Gaal, Research Volunteer, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Fellow, Robert Pivec, MD, Resident Physician, PGY-4, SUNY Downstate Medical Center, Brooklyn, New York, Kristy A. Fisher, MBA, MSc, St. George’s University, True Blue, Grenada
Background: Non-operative management of the elbow, shoulder, and knee typically includes braces, such as the: static progressive stretch (SPS), turnbuckle, and dynamic. However, a paucity of literature exists comparing these three bracing modalities. Therefore, the purpose of this study was to evaluate the current literature on the various bracing modalities for physicians and patients managing elbow, shoulder, or knee joint complications. Specifically, we compared the use of 1) static progressive stretch, 2) dynamic, and 3) turnbuckle braces for the a) elbow, b) knee, and c) shoulder.
Materials and Methods: A PubMed search on dynamic, SPS, and turnbuckle bracing for the elbow, knee, and shoulder joints was performed. Studies that addressed clinical outcomes and relied primarily on the brace for improvement of patient outcomes and not on surgery were included. Because individually-fabricated braces are extremely costly, require great fabrication skill, and are unique to the patient they were specifically designed for, their results are not generalizable to the greater patient population and were, therefore, not included in this analysis. A total of 14 elbow, 24 knee, and 4 shoulder studies met criteria.
Results: Elbow—Patients wore the SPS brace for 90 minutes, compared to 8 hours for the turnbuckle and 20 hours for the dynamic brace. The SPS and turnbuckle brace had similar increases in range of motion (ROM) of 37°. The SPS brace was found to provide patients with the greatest reduction in flexion contracture, 26°. There are similar increases in flexion ROM between the SPS and dynamic elbow bracing modalities.
Shoulder— The mean duration of use for an SPS was only six weeks compared to the two months required for the dynamic shoulder brace. The dynamic shoulder brace protocol involved upwards of 24 hours per day or night as patients were instructed to wear the brace at all times. Patients treated with both the SPS and dynamic braces had excellent pain outcomes.
Knee—The most commonly followed SPS knee brace protocol was one to three sessions per day which lasted from seven to nine weeks, while for the dynamic brace the time period ranged from six to eight weeks. The SPS brace reported a mean increase in ROM of 31°. There was a lack of evidence for the dynamic and turnbuckle knee braces for their accurate assessment. The SPS studies reported the greatest response to flexion improvement with a mean increase of flexion by 22°. Meanwhile, the reported mean flexion increase with a dynamic knee brace was only 7°.
Conclusion: Based on the most current literature available, the authors highly recommend the use of SPS for the elbow, shoulder, and knee. Static progressive stretch bracing has an easy patient protocol, a short duration of use, and excellent outcomes. Additionally, the lack of evidence for turnbuckle and dynamic braces is concerning. Overall, the static progressive stretch brace has shown excellent results in the outcomes assessed in this review and should be a first recommendation for patients suffering from elbow, knee, and/or shoulder pathology.
31/926
16-10-2017
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A Partial Posterior Bundle Ulnar Collateral Ligament Tear in a 10-year old Boy
Todd P. Pierce, MD, PGY1 Orthopaedic Resident, Jennifer Kurowicki, MD, Orthopaedic Surgery Research Fellow, Kimona Issa, MD, PGY4 Orthopaedic Resident, Anthony Festa, MD, Associate Professor, Vincent K. McInerney, MD, Orthopaedic Surgery Residency Program Director, Anthony J Scillia, MD, Associate Professor, Department of Orthopaedics, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey
Medial-sided elbow pain is becoming more common among pediatric overhead sport athletes. One potential cause of this is a partial or complete tear of the ulnar collateral ligament (UCL). Because the growth plate remains open in many of these athletes, the most common injury experienced is an avulsion at the medial epicondyle. However, although rare, there is a potential to tear the UCL, with the most common tears occurring at the anterior bundle. However, tears to the posterior bundle are quite rare in pediatric patients. We aim to describe the case of a 10-year old boy who was diagnosed with a partial posterior bundle UCL tear and was successfully treated by cessation of throwing activities and physical therapy. He was able to return to baseball 10 months after his diagnosis.
31/927
19-10-2017
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A Comparison of Relative Value Units in Primary versus Revision Total Ankle Arthroplasty
Nipun Sodhi, BA, Clinical Research Fellow, Benjamin Yao, BA, Case Western Reserve University, Jared M. Newman, MD, Research Fellow, Michael Jawad, BS, Research Volunteer, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Suela Lamaj, BS, Research Volunteer, Michael A. Mont, MD, Chairman, Cleveland Clinic, Cleveland, Ohio, George A. Beyer, MS, SUNY Downstate Medical Center, Brooklyn, New York, Alyeesha B. Wilhelm, BS, St. George’s University, True Blue Road, True Blue, Grenada
Introduction: To determine the effort required to provide a service, the United States Medicare uses Relative Value Units (RVUs). Consequently, higher RVUs are assigned to the procedures or services that require more effort, which ultimately means the physician will be properly compensated for the additional effort required. In total ankle arthroplasty (TAA), revision cases usually are more technically challenging and require more effort than primary TAA. Therefore, the purpose of this study was to compare the: 1) RVUs; 2) length-of-surgery; 3) RVU per unit of time between primary and revision total ankle arthroplasty; and 4) the individualized idealized surgeon annual cost difference analysis.
Materials and Methods: We utilized the American College of Surgeons, National Surgical Quality Improvement Program database from 2008 to 2015 to identify patients who underwent either a primary Current Procedural Terminology [CPT]: 27702) or revision (CPT: 27703) TAA. There were a total of 653 patients, 586 of which underwent a primary, and 67 who underwent a revision, TAA. The mean RVUs, length of surgery (in minutes), and RVU per minute, were calculated. Dollar amount per minute, per case, per day, and per year, to find an individualized idealized surgeon annual cost difference, were also calculated. An analysis of variance was used to compare variables between primary and revision TAA. A p-value of less than 0.05 was used to determine statistical significance.
Results: The mean RVU was significantly higher in revision versus primary TAA (16.93 vs. 14.41, p=0.001). However, there was no significant difference in the mean lengths of surgery between primary and revision TAA (160 vs. 157 minutes, p=0.613). Additionally, the mean RVU per minute was significantly higher in revision versus primary TAA (0.13 vs. 0.10, p=0.001).
Conclusion: Based on the results of this study, it appears that revision TAA cases are appropriately assigned a higher RVU per minute for performing them as they require more effort and are more challenging compared to the primary TAA. Furthermore, not only did the revision cases have lower mean lengths of surgery, but they also maintained a higher RVU per minute. Therefore, orthopaedists can use this information to further help them yield the best potential practice design.
31/929
7-10-2017
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Have the Yearly Trends of Total Hip Arthroplasty in Ankylosing Spondylitis Patients Decreased?
Lee Bloom, MD, Orthopaedic Surgery Resident, Jared M. Newman, MD, Research Fellow, Robert Pivec, MD, Orthopaedic Surgery Resident, Neil V. Shah, MD, MS, Research Fellow, Carl B. Paulino, MD, Assistant Professor of Orthopaedic Surgery, Director, Division of Spine Surgery, SUNY Downstate Medical Center, Brooklyn, New York, John J. Kelly, BS, St. George’s University School of Medicine, Grenada, West Indies, Nipun Sodhi, BA, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Jaiben George, MB, BS, Clinical Research Fellow, Research Fellow, Kim L. Stearns, MD, Orthopaedic Surgeon, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
Introduction: Ankylosing spondylitis (AS) is characterized by spinal inflammation and structural damage, primarily to the axial skeleton and sacroiliac joints. Between 25% and 70% of patients may experience progressive peripheral joint involvement, which, despite advancement in pharmacologic therapy, may necessitate surgical intervention. Total hip arthroplasty (THA) yields improved pain and functional outcomes for AS patients with hip involvement. It is unclear whether the annual rates of patients undergoing THA have changed due to newer pharmacologic management. Therefore, the purpose of this study was to evaluate the annual trends of AS patients who underwent THA. Specifically, we evaluated: 1) the annual trends of THAs due to AS in the United States population, and 2) the annual trends in the proportion of THAs due to AS in the United States.
Materials and Methods: This study used the Nationwide Inpatient Sample to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, an additional query was performed to identify THA patients who had a diagnosis of AS, defined by the International Classification of Disease 9th revision diagnosis code 720. The incidence of THAs with a diagnosis of AS in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of AS in patients who underwent THA.
Results: Review of the database identified 5,562 patients with AS who underwent THA. The overall annual prevalence of THA in the AS population significantly decreased during the 12-year study period from 2.24 per 1,000 THAs in 2002 to 1.73 per 1,000 THAs in 2013 (R2=0.445; p=0.018).
Conclusion: Annual THA trends in AS patients have significantly declined from 2002 to 2013. This decline may be attributed to improvements in medical management that delay the time from disease onset to requirement of a THA. Since THA is an option with advanced disease, the observed declining trends may indicate the efficacy of current medical management.
31/913
19-09-2017
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Trends and Epidemiology of Tennis-Related Sprains/Strains in the United States, 2010 to 2016
Jonathan D. Chevinsky, BFA, Jared M. Newman, MD, Research Coordinator, Neil V. Shah, MD, MS, Research Fellow, Neel Pancholi, MD, Orthopaedic Surgery Resident, John Holliman, MD, Family Medicine Resident, Ahmed Eldib, MD, Orthopaedic Surgery Resident, Qais Naziri, MD, MBA, Orthopaedic Surgery Resident, Scott E. Barbash, MD, Assistant Professor, William P. Urban, MD, Chairman, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, Nipun Sodhi, BA, Research Fellow, Cleveland Clinic, Cleveland, Ohio, Bashir A. Zikria, MD, MSc, Associate Professor, Johns Hopkins Health Care and Surgery Center, Bethesda, Maryland, John P. Reilly, MD, Director of Service, Staten Island University Hospital-Northwell Health, Staten Island, New York
Background: While tennis is one of the most popular sports in the world, it predisposes those who play it to a number of injuries. Several studies have shown sprains/strains to be the most common tennis-related injury. However, data is limited regarding trends in tennis-related sprains/strains. Therefore, this study evaluated: 1) trends in tennis-related sprains/strains; 2) trends in tennis-related sprains/strains by age; and 3) trends in the most common tennis-related sprained/strained body parts.
Materials and Methods: This study utilized the National Electronic Injury Surveillance System (NEISS) database to collect all tennis-related sprains/strains that occurred between January 1, 2010 and December 31, 2016. The annual trends of overall tennis-related sprains/strains were evaluated. Then, the trends in tennis-related sprains/strains by age groups (less than 14 years, 14 to 29 years, 30 to 54 years, and 55 years and older) were compared, and the tennis-related sprains/strains injuries of different body parts were evaluated.
Results: A total of 48,638 tennis-related sprains/strains occurred during the study period. There was a decrease in the annual estimated weights of sprains/strains, from 8,433 in 2010 to 5,326 in 2016 (p=0.094). When stratified by age, tennis-related sprains/strains occurred in 3,295 (6.8%) patients younger than 14 years, 15,169 (31.2%) patients between the ages of 14 and 29 years, 16,814 (34.6%) patients between the ages of 30 and 54 years, and 13,360 (27.5%) in patients 55 years and older. Also, the trends tended to decrease for every age group, but this was not statistically significant. Furthermore, the most common tennis-related sprains/strains involved the ankle (30.2%), knee (13.7%), lower leg (11.3%), wrist (10.3%), lower trunk (8.5%), shoulder (8.1%), foot (4.9%), and elbow (2.5%). There was a significant decrease in the annual trends of ankle sprains/strains over the study’s time-period (p=0.003).
Conclusion: Sprains/strains were the most common tennis-related injuries, and the trends decreased over time, regardless of age. The lower extremity was more commonly injured than the upper extremity, with the ankle being the most common location. Understanding incidence and trends of tennis-related sprains/strains may help elucidate uncertainty pertaining to tennis injury statistics, ultimately improving the ability-of-care providers to work with players to develop preventive measures and better guide treatment.
31/922
28-10-2017
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Hemiarthroplasty For Fractures of Metastatic Bone Disease Have Different Outcomes Compared to Fractures Without Metastasis: A Matched-Pair
Samuel Rosas, MD, Resident Physician Scientist, Alejandro Marquez-Lara, MD, Resident, Physician Scientist, Alexander H. Jinnah, MD, Resident Physician Scientist, Cynthia L. Emory, MD, MBA, Associate Professor Department of Orthopedic Surgery, Jeffrey S. Willey, PhD, Assistant Professor, Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, Martin W. Roche, MD, Attending Orthopedic Surgeon, Holy Cross Orthopedic Institute, Fort Lauderdale, Florida, Chukwuweike Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
Introduction: Hemiarthropalsty (HA) for proximal femur fractures (PFF) has shown good results in the elderly patient population. It has also been used to treat fractures of the proximal femur in patients with metastatic bone disease (MBD). Nonetheless, complications still occur in both patient populations and their effect on 90-day costs can be a great burden to the healthcare system. Thus, the purpose of this study was to evaluate and compare the outcomes and costs of HA for PFF in patients with bone metastasis versus those without it.
Materials and Methods: The Medicare standard analytical files were queried through International Classification of Diseases and Related Health Problems, ninth edition (ICD-9) codes. A case-control study comparing PFF in patients with and without MBD treated with HA was performed. Medical and surgical complications, mortality, discharge disposition, and length of stay were analyzed and compared. Outcomes were tracked for the 90-day period after surgery. Statistical analysis was performed through odds ratios, unpaired t-tests, and chi-squares.
Results: Patients treated with HA for fractures with MBD have higher rates of medical complications compared to fracture patients without MBD. Mortality was found to be significantly greater in the MBD cohort (8.8% vs. 2.3%), as were medical complications and length of stay. Both charges and reimbursements were also significantly greater in the MBD cohort.
Conclusion: Patients who undergo hip HA for MBD are at increased risks of medical complications compared to patients who undergo HA for fractures without metastasis, and surgeons should be aware of these increased risks.
31/930
4-10-2017
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The Addition of Diclofenac to Multimodal Pain Control Regimen Decreases Postoperative Pain and Opioid Consumption
Nicole E. George, DO, Research Fellow, Cheryle Gurk-Turner, RPh, Clinical Pharmacist, Pain Management Specialist, Jennifer I. Etcheson, MD, MS, Research Fellow, Chukwuweike U. Gwam, MD, Research Fellow, Randal De Souza, BS, Research Assistant, James Nace, DO, MPT, Fellowship Director/Academic Director, Rubin Institute Adult Hip and Knee Reconstruction Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Spencer S. Smith, DO, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
Introduction: Total knee arthroplasty (TKA) is a commonly-performed orthopaedic procedure in the United States. However, inadequate postoperative pain management following TKA has been associated with a number of negative consequences, including chronic postoperative pain requiring long-term opioid use. Multimodal pain control is a recently-popularized means of maximizing analgesia and postoperative outcomes. We aimed to evaluate the outcomes of a multimodal pain regimen incorporating diclofenac, including: 1) length of stay (LOS); 2) pain intensity; and 3) opioid consumption in primary TKA patients.
Materials and Methods: A prospective cohort study was performed. All patients scheduled for primary TKA by a single surgeon between March 1, 2017 and August 31, 2017 were screened for study involvement, yielding 46 consecutive patients (52 TKAs). This study group was treated with a postoperative regimen of intravenous (IV) diclofenac, in addition to a perioperative pain control regimen including adductor canal blockade (ACB) and periarticular multimodal drug injection (PMDI). Postoperative outcomes in this group were compared to those of a matched cohort of 78 patients (88 primary TKAs) who had previously been treated with the same perioperative pain control regimen.
Results: Patients prescribed a postoperative diclofenac regimen had lower mean LOS (2.10 vs. 2.33 days; p=0.053) and lower 24-hour postoperative pain intensity (76 vs. 104; p=0.056) as compared to the untreated group. The diclofenac-treated group had a significantly lower opioid consumption in the first 24 hours postoperatively than did their untreated counterparts (39.8 vs. 53.1 morphine milligram equivalents [MME]; p=0.041). In addition, 17 patients (18 TKAs, 35%) in the diclofenac group had zero opioid requirements during the first 12 hours postoperatively, and 12 of these patients (13 TKAs, 25%) continued to not require any opioids through the first 24 hours postoperatively.
Discussion: In the midst of the rapidly-increasing rates of TKA in the US, multimodal pain control has emerged as an extremely effective means of maximizing postoperative patient outcomes. To our knowledge, this is the first study to evaluate the postoperative outcomes of TKA patients treated with a regimen of IV diclofenac. We demonstrate shorter LOS, decreased 24-hour pain intensity, and significantly decreased 24-hour opioid consumption in patients treated with adjunctive IV diclofenac compared to patients managed with our institution’s standard perioperative regimen.
31/932
25-10-2017
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Demographics of Tennis-Related Injuries that Presented to Emergency Departments in the United States
Jonathan D. Chevinsky, BFA, Neil V. Shah, MD, MS, Orthopaedic Surgery Research Fellow, Mikhail Tretiakov, MD, Orthopaedic Surgery Resident, Alexandr Aylyarov, MD, Orthopaedic Surgery Resident, Gregory S. Penny, MD, Orthopaedic Surgery Resident, Joanne C. Dekis, MD, Orthopaedic Surgery Resident, William P. Urban, MD, Chairman, Carl. B. Paulino, MD, Assistant Professor of Orthopaedic Surgery, Director of Spine Surgery, Jared M. Newman, MD, Orthopaedic Surgery Research Coordinator, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, Jonathan N. Chorney, MD, Family Medicine Physician, Desert Bloom Family Medicine, Phoenix, Arizona, Natasha Ahmed, BS, Saba University School of Medicine, C/O R3 Education Inc., Devens, Massachusetts, Nipun Sodhi, BA, Clinical Research Fellow, Cleveland Clinic, Cleveland, Ohio, Alyeesha B. Wilhelm, BS, St. George’s University School of Medicine, University Centre, Grenada, West Indies
Introduction: Forced-air warming devices have been reported to present a potential risk for surgical site infections (SSIs) and periprosthetic joint infections. Due to a lack of consensus, we reviewed the infection risk of forced-air warming devices.
Materials and Methods: A systematic literature review was performed, evaluating overall infection risk and bacterial load. A total of eight studies reporting outcomes from 1,965 subjects were included.
Results and Conclusions: There is no current evidence in the orthopaedic literature that forced-air warming devices translate to increased SSIs. Accordingly, these devices should continue to be used for the maintenance of intraoperative normothermia.
31/933
10-10-2017
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Cellular Therapies in Orthopaedics: Where Are We?
Nicolas S. Piuzzi, MD, Clinical Scholar, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Sameer Oak, MD, Orthopaedic Resident, PGY-2, Assem A. Sultan, MD, Clinical Research Fellow, Morad Chughtai, MD, Resident, PGY-1, Venkata P. Mantripragada, PhD, Postdoctoral Fellow, Michael A. Mont, MD, Chairman, George F. Muschler, MD, Vice Chair, Cleveland Clinic, Cleveland, Ohio
The orthopedic field has experienced several major practice-changing pivotal shifts in the past several decades, such as the invention and application of the arthroscope or the implementation and advancement of joint arthroplasties. Most of these previous breakthroughs have focused on surgical techniques and devices. However, the next major advance in the field is likely to be related to biologic treatments. Although still in its early stage of development, orthopedic regenerative medicine, including cellular therapies, represents a great opportunity, since we are only beginning to understand their biological potential. The main challenge in this pathway is to translate the promising results obtained by basic scientists to clinical practice. This work reviewed the market and clinical evidence, as well as future perspectives, concerning cellular therapies in orthopedics.
31/934
18-11-2017
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van Neck-Odelberg Disease: A 3.5-Year Follow-Up Case Report and Systematic Review
Patrick J. Mixa, MD, Research Fellow, Frank A. Segreto, BA, Research Assistant, Hiram Luigi-Martinez, MD, Bassel G. Diebo, MD, Orthopaedic Surgery Resident, Qais Naziri, MD, MBA, Orthopaedic Surgery Resident, Srinivas Kolla, MD, Assistant Professor, Aditya V. Maheshwari, MD, Assistant Professor, State University of New York, Downstate Medical Center, Brooklyn, New York
Van Neck-Odelberg disease (VND) is a benign skeletal overgrowth of the ischiopubic synchondrosis (IPS) in prepubescent patients. There is a paucity of long-term follow-up data and reviews on management decision-making. We report on a 15-year-old female, with a history of sickle-cell disease (HbSS), presenting with unilateral groin pain. Patient’s physical examination, radiographs, and a literature-review determined a diagnosis of VND. Conservative treatment was issued. Clinical symptoms resolved at three months, followed by complete lesion resolution at three years. Additionally, a search of Medline (PubMed), EMBASE, and OVID databases was performed. Reports including VND/IPS diagnosis, treatment, or follow-up decisions were identified. Systematic-review found 17 relevant articles, reporting on 29 patients. Patients presented with groin (51.7%) or buttock (20.7%) pain, and were diagnosed using X-ray (n=23) and magnetic resonance imaging (MRI) (n=17). Twenty-five patients were treated conservatively, with two (8.0%) reports of surgical intervention. Average follow-up was 6.25 months. Our case report and systematic-review support conservative treatment for VND.
31/935
1-10-2017
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Radiographic Classification Systems for Osteonecrosis of the Knee: A Review of Literature
Assem A. Sultan, MD, Clinical Research Fellow, William A. Cantrell, BS, Morad Chughtai, MD, PGY-1 Orthopaedic Surgery Resident, Prem N. Ramkumar, MD, MBA, Resident, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Suela Lamaj, BS, Research Volunteer, Timothy C. Wagner, MD, PGY-5 Orthopaedic Surgery Resident, Linsen T. Samuel, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Fellow, SUNY Downstate Medical Center, Brooklyn, New York
Knee osteonecrosis is a rare, yet debilitating disease that can lead to knee joint destruction and can be associated with significant pain and disability. Various imaging modalities have different roles in the diagnosis, staging, management, and determination of the prognosis in knee osteonecrosis. Plain radiographic images can show gross joint destruction and secondary arthritic changes. In addition, magnetic resonance imaging (MRI) has become the gold-standard imaging modality to diagnose osteonecrosis. Multiple classification systems have been developed for knee osteonecrosis based on these imaging modalities. The goal of these systems is to stage the disease and guide management. Better understanding of the pattern of the lesions and its morphometric characteristics may allow surgeons to reach a better consensus regarding the timing of surgical treatment, choice of implant, and overall disease prognosis in these unique patients. Due to the relative paucity of evidence, this review was conducted to evaluate different radiological classification systems utilized in osteonecrosis of the knee joint.
31/936
22-10-2017
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Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?
Dean C. Perfetti, MD, Orthopaedic Surgery Resident, Long Island Jewish, New Hyde Park, NY, Nipun Sodhi, BA, Research Fellow, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Research Fellow, Suela Lamaj, BS, Research Volunteer, William A. Cantrell, BA, Medical Student, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Mathew R. Boylan, MD, MPH, Orthopaedic Surgery Resident, NYU Hospital for Joint Diseases, New York, New York, Jared M. Newman, MD, Research Coordinator, Qais Naziri, MD, MBA, Orthopaedic Surgery Resident, Aditya V. Maheshwari, MD, Director, SUNY Downstate Medical Center, Brooklyn, New York, Carl B. Paulino, MD, Director, Adult Reconstruction and Musculoskeletal Oncology, Brooklyn, New York
Introduction: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA).
Materials and Methods: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery.
Results: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081).
Conclusions: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.
31/937
31-10-2017
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Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy
Sarmistha Pal, PhD, Research Scientist, Joan E. DaVanzo, PhD, MSW, Chief Executive Officer, Dobson DaVanzo & Associates, Vienna, Virginia, Morad Chughtai, MD, Resident, PGY-1, Assem A. Sultan, MD, Clinical Research Fellow, Anton Khlopas, MD, Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Jared M. Newman, MD, Clinical Research Fellow, Linsen T. Samuel, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Nicole E. George, DO, Research Fellow, Jennifer I. Etcheson, MS, MD, Research Fellow, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Anil Bhave, PT, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
Introduction: This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy.
Materials and Methods: We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission.
Results: A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively.
Conclusion: Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.
31/945
13-10-2017
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Can Stem Version Consistently Correct Native Femoral Version Using Robotic Guidance in Total Hip Arthroplasty?
Benjamin G. Domb, MD, Orthopedic Surgeon, Medical Director, Sivashankar Chandrasekaran, MBBS, FRACS, Orthopedic Surgeon, Chengcheng Gui, BS, Research Assistant, Leslie C. Yuen, BA, Research Assistant, Parth Lodhia, MD, FRCSC, Orthopedic Surgeon, Carlos Suarez-Ahedo, MD, Orthopedic Surgeon, Hinsdale Orthopaedics, American Hip Institute, Westmont, Illinois
The purpose of this study is to investigate whether robotic guidance in total hip arthroplasty (THA) can consistently correct native femoral version. One hundred seventy-five consecutive patients who underwent MAKO® (Stryker, Kalamazoo, Michigan) robotic-guidance THA were included in the study. The study population had a mean age of 57.9 years and a mean body mass index (BMI) of 30.41. Forty-eight percent of the population was male and 74% of the procedures were performed through an anterior approach. Robotic guidance in THA was effective in correcting native femoral version toward a target of 15°. This can be achieved using both the anterior and posterior approach; it is not affected by BMI.
31/891
10-12-2017
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