Surgical Technology International
34th edition
Contains 67 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
521 pages
May 2019 - ISSN:1090-3941
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both electronic and print versions
Orthopaedic Surgery
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
1082
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
1081
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
1075
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
1140
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
1136
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
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
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
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
1128
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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