Surgical Technology International
37th Edition
Contains 62 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
432 pages
Nov 2020 - ISSN:1090-3941
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both electronic and print versions
Comparison of Clinical and Radiological Outcomes of Three Modern Stem Designs in Total Hip Arthroplasty with Minimum Two-Year Follow Up
Akhil Katakam, MBA, Christopher M. Melnic, MD, Hany S. Bedair, MD, Associate Professor, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
1305
Introduction: Recent changes in stem design for total hip arthroplasty (THA) complicate the daunting task of the orthopaedic surgeon to choose the best stem for patients. The purpose of our study was to report the early- to mid-term clinical and radiological outcomes of three unique stem designs used for THA using primarily a posterolateral approach.
Materials and Methods: A retrospective study was performed at a single healthcare system between January 2007 and March 2018 to identify THA patients who received a stem belonging to the Taplerloc® Complete Hip System (Zimmer-Biomet, Warsaw, Indiana). Stems were then stratified into full-length, standard profile, full-length, reduced distal profile, and short-length, standard profile cohorts. Demographic, radiological, and clinical outcome variables were collected for each patient and compared between stem cohorts.
Results: 538 THAs (248 full-length, reduced distal; 202 full-length, standard profile; 88 short-length, standard profile) were analyzed. One patient in the full-length, reduced distal cohort suffered a perioperative fracture following implantation of the stem. There were a total of 29 postoperative complications at most recent follow up, nine (3.6%) in the full-length, reduced distal group, 12 (5.9%) in the full-length, standard profile group, and eight (9.1%) in the short-length, standard profile group, with no difference in rates of complication between groups (p=0.136). No difference in complication rates was observed when only posterolateral cases were considered (p=0.05). Survivorship of each stem group was 99.6%, 98.5%, and 96.6%, respectively. Limb length discrepancy and stem subsidence were found to be similar between groups based on measurements taken at most recent clinical follow up.
Conclusion: Our findings suggest that shortened length and reduced distal profile features result in no added benefit regarding intraoperative and postoperative clinical or radiological outcomes.
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Long-Term Outcomes of a Modular System in Revision Total Knee Arthroplasty
Braden J. Passias, DO, OhioHealth, Columbus, Ohio, Joanne B. Adams, BFA, CMI, Adolph V. Lombardi Jr., MD, FACS, Keith R. Berend, MD, David A. Crawford, MD, Joint Implant Surgeons, Inc., New Albany, Ohio
1313
Introduction: With the growing demand for total knee arthroplasty (TKA), the burden of revision surgery will continue to rise. Revision knee arthroplasty has historically had worse survivorship than primary knee arthroplasty. The purpose of this study is to review the 10-year outcomes and survivorship of a modular revision knee system.
Materials and Methods: A retrospective review was conducted on 109 patients (117 knees) who underwent a revision knee arthroplasty with the Vanguard® Super Stabilized Knee (SSK) Revision System (Zimmer Biomet; Warsaw, Indiana) who were eligible for 10-year minimum follow up. Clinical and radiographic data was obtained pre- and postoperatively, six weeks postoperatively, and then every year thereafter.
Results: With an average follow up of 10.7 years (range, 2.3 to 14.1 years), the SSK revision system exhibited a notable improvement in both clinical and functional outcomes. Average knee range of motion improvement was 4.2 degrees (SD ±18). Manipulations under anesthesia were performed in six knees (5%). Re-revisions occurred in 27 knees (23%). Ten of the re-revisions were for aseptic loosening (37%), eight for periprosthetic infection (30%), five for instability (19%), and the remainder for other aseptic causes. Mean time to failure was 4.6 years (range, 1 to 9.1 years). The 10-year all-cause survival was 77% (95% confidence interval [CI], 73 to 81%). The 10-year aseptic survival was 83% (95% CI, 79 to 87%).
Conclusion: The findings of this study show an 83% 10-year aseptic survivorship with the Vanguard® SSK knee revision system. These results are comparable to long-term follow up of other revision knee systems.
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Computer Navigation Technique for Simultaneous Total Knee Arthroplasty and Opening Wedge High Tibial Osteotomy in Patients with Large Tibial Varus Deformity
Jacques Heringou, MD, Xavier Morel, MD, Department of Orthopaedic and Traumatology Surgery, EpiCURA hospital, Baudour/Hornu, Belgium Philippe Heringou, MD, Department of Orthopaedic and Traumatology Surgery, Henri Mondor Hospital, University of Paris, Paris, France
1367
Introduction: Total knee arthroplasty (TKA) in patients with established knee osteoarthritis and major varus, mostly due to constitutional proximal deformity, remains a challenging procedure. Orthogonal cuts result in asymmetric bone resection and subsequent bone-related laxity or difficult release. A procedure that combines opening high tibial osteotomy (HTO) and TKA in the same sitting to address such major deformities is possible. But for this combined operation, precise planning and an exact intraoperative transformation of the planning is required. The assumption that the results could be predicted better by means of a navigation system was analyzed.
Materials and Methods: The precision of surgery with computer-based navigation was compared to conventional surgery. A comparative prospective study was conducted using an expert surgeon. Between 2005 and 2015, we performed 20 procedures on knees with average preoperative 18° (range, 15–25°) varus. Tibial valgus osteotomy plus TKA was performed in one sitting. It allows the surgeon to do a more sparing medial release and to achieve proper realignment with a concomitant well-balanced prothesis. A group of 10 patients had conventional surgery and the other 10 had surgery performed with computer-based navigation for both osteotomy and TKA. By means of this system, the desired mechanical axis is obtained with real-time monitoring of the coronal and sagittal plane on the navigation without intraoperative x-ray control. The positioning of the saw-jigs for the femoral and tibial cuts of the arthroplasty was also performed with the help of the navigation system.
Results: Postoperative mean femorotibial varus was 1.5° (range, 0–5°) with better alignment for the computer-based navigation. The mean correction following osteotomy was 16° (range, 12–24°). The intraarticular part of the deformity due to cartilage wear was addressed by the TKA. No release was done during surgery. The patients were mobilized early with limitation in range of motion up to 90° of flexion during the two weeks and were allowed full weight after. No instability and no complications were observed. On assessing radiological coronal alignment of the prostheses, there was better alignment of 0.5° varus (range, 0–3° of varus) in the computer navigation group compared to the traditional group (2.5° varus; range, 1–5° of varus). The navigation group showed better tibial slope maintenance (mean change, + 0.5°, p=0.732), whereas it was increased significantly in the conventional group (mean change, +4.2°, p<0.01). The average number of fluoroscopy shots for the computer navigation group was 2.8 (95% CI, 1.2–6.5) versus 9.4 in the control group (95% CI, 5.3–12.4). This represented a shorter (p<0.001) time of 11.4 seconds of irradiation for the computerized navigation technique compared to 36.2 seconds of irradiation for the traditional technique.
Conclusions: Computer navigation improved precision with less radiation. The findings of this study suggest that computer navigation may be safely used in a complex procedure when combined with total knee arthroplasty and opening wedge high tibial osteotomy in one sitting.
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Robotic-Assisted Versus Manual Unicompartmental Knee Arthroplasty: A Systematic Review
Cesar Iturriaga, DO, Nipun Sodhi, MD, Long Island Jewish Medical Center, Northwell Health, New York, New York, Hytham S. Salem, MD, Joseph O. Ehiorobo, MD, Michael A. Mont, MD, Lenox Hill Hospital, Northwell Health, New York, New York
1316
Introduction: Unicompartmental knee arthroplasty (UKA) is a feasible alternative to total knee arthroplasty (TKA) for selected patients with severe single-compartment knee osteoarthritis. Robotic-assisted UKA (rUKA) has recently emerged as a complementary tool to ameliorate previous difficulties with manual UKA (mUKA). However, the influence of rUKA compared to mUKA on patient outcomes are still largely unknown.
Purpose: To compare outcomes of the manual technique and a single robotic-assisted system in patients undergoing unicompartmental knee arthroplasty.
Materials and Methods: The PubMed-Medline was searched using terms: “robotic,” “unicompartmental,” “knee,” and “arthroplasty” to identify all studies comparing outcomes of mUKA and rUKA. Data pertaining to the following outcomes were extracted: (1) studies comparing robotic-assisted UKA to manual UKA; (2) reports which only included the Mako UKA system (Mako Surgical Corporation, Fort Lauderdale, Florida) as the robotic-assisted system; and (3) studies which discussed implant survivorship, complications, early postoperative parameters, functional outcomes, or implant positioning. Review articles were excluded.
Results: A total of eight publications with 337 patients who underwent rUKA and 481 who underwent mUKA were included in our analysis. Two studies reported that early postoperative pain was decreased with rUKA compared to mUKA. In one study, pain levels in the first eight postoperative weeks were 54% lower in the rUKA group and in the other, pain scores based on the numeric rating scale were significantly lower in rUKA (2.5) compared to mUKA (4.2) upon discharge (p<0.001). Furthermore, mean time to hospital discharge in this study was reduced with rUKA (42.5 ± 5.9 hours) compared to mUKA (71.1 ± 14.6 hours) (p<0.001). One study demonstrated a significant improvement in range of motion at two-year follow up in the rUKA group (15°, range, 5° to 25°) compared to the mUKA group (10°, range 0° to 20°; p=0.04). One study reported that at three-month follow up, mean Knee Society scores were significantly better in the rUKA group (164; interquartile range [IQR] 131 to 178) compared the mUKA group (143; IQR 132 to 166; p=0.04). Three studies reported more accurate implant positioning with rUKA compared to mUKA. Among the five studies that reported implant survivorship, four studies (including a randomized control trial) found no difference between techniques in implant survival rate, while one retrospective analysis reported improved survivorship with mUKA.
Conclusions: In conclusion, unicompartmental knee arthroplasty implants demonstrated comparable survivorship rates whether performed manually or with robotic assistance. However, compared to the manually performed procedure, robotic-assisted unicompartmental knee arthroplasty were found to offer benefits including shorter lengths of hospital stays, decreased postoperative pain scores, and improved functional outcomes.
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Opioid Use in Robotic-Arm Assisted Total Knee Arthroplasty: A Comparison to Conventional Manual Total Knee Arthroplasty
Justin J Greiner, MD, Jesse F Wang, MS, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, Scott J Hetzel, MS, Eric J Lee, MD, Richard L Illgen, MD, Professor, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, Joseph Mitchell, MD, University of California San Diego, San Diego, California
1358
Introduction: Opioids are frequently prescribed in the postoperative management of total knee arthroplasty (TKA) with multiple factors influencing postoperative opioid use. Robotic-arm-assisted TKA (raTKA) was developed with the goal of improving alignment and outcomes while decreasing soft tissue injury. The purpose of this study was to compare postoperative opioid consumption in raTKA and conventional manual TKA (mTKA) cohorts.
Materials and Methods: A consecutive series of unilateral primary TKAs performed 1/1/16 to 12/31/17 were included. Patients with major procedures requiring opioids occurring within one year of TKA were excluded. A single-surgeon raTKA cohort of 127 patients (Group 1) was compared to a same-surgeon cohort of 119 mTKAs (Group 2) using the same cemented implant design and a two-surgeon cohort of 410 mTKA (Group 3). Groups were subdivided into opioid naïve (ON) and opioid exposed (OE). Length of hospitalization and postoperative opioid utilization up to one year were compared between groups and collectively without separating raTKA and mTKA. Statistical analysis included Chi-square, Student’s t-test, and Wilcoxon rank sum tests.
Results: For both ON and OE patients, Group 1 demonstrated reduced inpatient mean daily oral morphine milligram equivalent (MME) compared to Group 3 (ON p=0.007; OE p=0.034), a shorter hospitalization compared to Group 2 (ON p=0.02; OE p=0.012), and fewer opioids prescribed at discharge compared to Group 2 (ON p=0.005; OE p=0.081) and Group 3 (ON p<0.001; OE p=0.036). No differences in opioid prescriptions were seen at three months or after. Regardless of surgical technique OE patients had higher inpatient opioid utilization (p<0.001) as well as cumulative outpatient prescription quantity (MME 1050 ON, 2660 OE) and duration (ON 0.5%; OE 28.3%) at one year (p<0.001).
Conclusion: Less opioids were prescribed at discharge and used during hospitalization in raTKA compared to mTKA though no differences in opioid use were seen at further time points. Preoperative opioid use remains a dominant factor in postoperative opioid utilization regardless of TKA surgical technique.
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The Use of New Technology for Wound Management Following Total Knee Arthroplasty: Implications for the COVID-19 Crisis
John M. Tarazi, MD, Brandon H. Naylor, DO, Hytham S. Salem, MD, Michael A. Mont, MD, System Chief of Joint Reconstruction, Northwell Health Orthopedics, Lenox Hill Hospital, New York, New York
1325
With constantly evolving materials and techniques used in wound closure management for total knee arthroplasty (TKA), it is imperative that we continuously evaluate new modalities and techniques to optimize healing. This article provides a concise review of the current closure and wound management methods for each of the following three layers and dressing: 1) deep fascia layer, or arthrotomy; 2) subdermal layer or subcutaneous layer; 3) skin and subcuticular layer; and 4) dressing application. By introducing a comprehensive and systematic approach to TKA wounds, this report also incorporates newer modalities such as barbed sutures and adhesive dressings, which have increasingly replaced traditional suture and staple methods. Furthermore, we examine how various layers of modern wound closure compare to conventional methods while discussing both the clinical and economic impacts of each. Newer wound management methods, such as the adhesive and occlusive dressings with varying monofilament subcuticular sutures, can eliminate the need for staple and suture removal, increase the value of care provided, limit unnecessary postoperative visits, and potentially address wound issues by communicating safely with patients via telemedicine, an ever-relevant discussion in the era of coronavirus disease 2019 (COVID-19).
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Active Robotic Total Knee Arthroplasty (TKA): Initial Experience with the TSolution One® TKA System
Jason Chan, MD, Thomas S. Auld, MD, Rutgers New Jersey Medical School, Newark, NJ, Bernard Stulberg, MD, St. Vincent Charity Medical Center, Cleveland, OH, William J. Long, MD, FRCSC, Clinical Associate Professor, NYU, New York, NY, Stefan Kreuzer, MD, MSc, INOV8 Orthopedics, Houston, TX, Valentina Campanelli, PhD, THINK Surgical, Inc., Fremont, CA, Ralph Liebelt, MD, EmergeOrtho, Durham, NC , Yair D. Kissin, MD, Hackensack University Medical Center, Hackensack, NJ, Assistant Clinical Professor, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ
1307
Several recent advances, including the use of robotic devices, have been explored to improve outcomes in total knee arthroplasty (TKA). The TSolution One ® Total Knee Application (THINK Surgical, Inc., Fremont, CA, USA) introduces an active robotic device that supports an open implant platform and CT-based preoperative planning workflow, and requires minimal surgeon intervention for making bone cuts.
Our experience was part of a multi-center, prospective, non-randomized trial assessing the safety and effectiveness of this active robotic system for TKA. Each patient underwent a preoperative CT-scan, which was uploaded to proprietary planning software. The surgeon reviewed the software-generated 3D digital model, selected the appropriate implants and generated a final preoperative plan.
Intra-operatively, a standard medial parapatellar approach was used. The leg was then rigidly attached to the robot via fixation pins, and registration markers were placed in the tibia and femur. Landmark registration was performed to inform the robot of the knee’s position in space and to confirm the robot’s ability to execute the preoperative plan. Next, the robot performed femoral and tibial cuts using a cutter in a sequential fashion along a defined cut-path. The robot was then removed from the operative field and the surgeon completed the procedure by removing marginal bone and performing final balancing and implantation in the usual fashion.
The TSolution One® Total Knee Application is a computer-assisted device that potentially allows a surgeon to make more accurate cuts and to determine optimal implant position based on the patient’s specific anatomy. It is the only active robotic system currently available.
In this manuscript, we describe the operative technique and workflow involved in performing this surgery and offer insight on optimizing safety and efficiency as we introduce new technologies to the operating theater. We also present two cases performed by the senior author to further demonstrate technical aspects of the procedure.
Transferable Global Rating Scales in the Validation of the ArthroSim™ Virtual Reality Arthroscopy Simulator
Alex Mulligan, MA, MBBS, FRCS (Tr & Orth), Kalpesh R. Vaghela, MBBS, BSc, MSc, FRCS (Tr & Orth), Luckshman Jeyaseelan, MBBS, BSc, FRCS (Tr & Orth), Josh Lee, BSc (Hons), MBChB, MSc, FRCS (Tr & Orth), Kash Akhtar, MBBS, MSc, Med, MD, FRCS (Tr & Orth), The Royal London Hospital, Barts Health NHS Trust, Whitechapel, UK
1315
Introduction: Virtual reality arthroscopic simulators are becoming increasingly prevalent in the orthopaedic training environment. The construct validity of the ArthroSim™ virtual reality simulator (TolTech Touch of Life Technologies, Aurora, Colorado) has been established based on time to completion comparison between candidates of differing levels of surgical experience. This study aims to establish the construct validity of the ArthroSim™ virtual reality simulator using validated global rating scales that allow direct comparison with intraoperative performance.
Materials and Methods: Eight novices (medical students), eight intermediates (registrars), and seven experts (consultants) were assessed using the Imperial Global Arthroscopy Rating Scale (IGARS) and the Arthroscopic Surgical Skills Evaluation Tool (ASSET) scoring systems while carrying out a standardised basic diagnostic knee arthroscopy using linked and anonymised recordings of both the arthroscopy video output and candidate’s hand posture and position. Time to completion was recorded and the expert group also filled out questionnaires assessing the face and content validity of the simulator.
Results: The mean IGARS/ASSET scores for the novice, intermediate and expert groups were 14/11, 29/22, and 46/36 respectively. The difference in score between each of the groups was statistically significant (p<0.05). The average time to completion was 257 seconds, 305 seconds, and 204 seconds respectively. The time to completion was not significantly different between the groups (p=0.6).
Conclusions: The ArthroSim™ virtual reality simulator could effectively distinguish between candidates of differing experience levels using validated global rating scales and therefore demonstrated construct validity.
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Effectiveness of a Simple Auditory Feedback Insole (Sim-Insole) for Touchdown Weight-Bearing Training in At-Risk Volunteers with Poor Compliance: A Crossover Study
Chaiyanun Vijittrakarnrung, MD, Paphon Sa-ngasoongsong, MD, Associate Professor, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, Udomporn Manupibul, Warakorn Charoensuk, Ph, Assistant Professor, Ratikanlaya Tanthuwapathom, Mahidol University, Nakhon Pathom, Thailand, Wimonrat Jarumethitanont, Mahidol University, Nakhon Pathom, Thailand
1332
Introduction: Recent studies have shown that biofeedback devices are effective for weight-bearing (WB) training. However, these devices have limitations due to high costs and inadequate evidence of their effectiveness among poor-compliance individuals. This study aimed to assess WB compliance after touchdown weight-bearing (TDWB) training by the standard bathroom scale (BS) method and to evaluate the efficacy of our innovative simple auditory feedback device (Sim-Insole).
Methods: In this crossover study, healthy volunteers were trained for TDWB (targeting 20% of bodyweight [BW]) with the BS method and assessed with the Sim-Insole without feedback (phase 1), and then completed a 30-min wash-out period and underwent re-assessment with Sim-Insole with feedback (phase 2). Satisfaction was evaluated with a self-assessment questionnaire. Those who had and had not experienced a weight-bearing force (WBF) >25% of BW were classified as high-risk and low-risk groups, respectively. Steps with percentage of WB <15%, 15%–25%, and >25% were defined as under-zone, in-zone, and over-zone, respectively.
Results: Fourteen volunteers (70%) were classified as high-risk after the BS method. Without auditory feedback, the high-risk group demonstrated a significantly higher average percentage of WB and higher average lowest WBF compared to the low-risk group (18.8% vs. 13.7% and 74.3N vs. 60.2N, respectively, p=0.002 for both). With the use of auditory feedback with Sim-Insole in the high-risk group, the cadence, percentage of WB, highest absolute WBF, proportion of over-zone step, and confidence for TDWB improved significantly compared to those with the BS method (p<0.05 for all). However, the low-risk group showed only a significant improvement in cadence (p=0.047) and a non-significant trend for improvement in the percentage of WB (p=0.089), compared to the BS method.
Conclusion: Sim-Insole is effective for TDWB training. This device significantly improved WB compliance with regard to excessive WB, walking speed, and the confidence of volunteers in the high-risk group with poor compliance.
Biomechanical Assessment of a Novel Posterior Soft Tissue Repair Technique in Primary Total Hip Arthroplasty
Sean A. Sutphen, DO, Illinois Bone and Joint Institute, Chicago, Illinois, Peter B. White, DO, MS, Northwell Health – Plainview Hospital, Plainview, New York, Amar S. Ranawat, MD, Hospital for Special Surgery, New York, New York
1324
Introduction: Instability is one of the most common complications after total hip arthroplasty (THA), particularly when using the posterior approach. Repair of the posterior capsule has proven to significantly decrease the incidence of posterior hip dislocation. The purpose of the present study is to evaluate if a racking hitch knot utilizing a 2mm braided polyblend suture provides a stronger repair of the posterior soft tissues when compared to a traditional repair utilizing a non-absorbable suture after a posterior approach to the hip.
Materials and Methods: Ten cadaveric hips from donors, who were at a mean age of 80 ± 9 years old at the time of death, were evaluated after posterior soft tissue repair utilizing two different techniques. Five specimens were repaired utilizing a racking hitch knot with a 2mm braided polyblend suture (FiberTape®, Arthrex GmbH, Naples, Florida) and five other specimens were repaired with a traditional repair using a no. 2 non-absorable suture (FiberWire®, Arthrex GmbH, Naples, Florida). Cadaveric specimens were matched based upon age, sex, and laterality. Biomechanical tensile testing using the Instron E10000 Mechanical Testing System and the mechanisms of failure (MOF) were assessed.
Results: The ultimate load to failure was three times higher using braided polyblend sutures (390.00 ± 129.08 N) compared to non-absorbable sutures (122.81 ± 82.41 N) after posterior soft tissue repair (p< <0.01). In the braided polyblend suture cohort, the mechanism of failure most commonly occurred as the braided suture pulled through the posterior soft tissues. However, in the non-absorbable suture repair, failure took place at the suture knot.
Conclusion: The use of our posterior capsular repair utilizing a braided polyblend suture and racking hitch knot provides for a stronger repair of the posterior soft tissues when compared to non-absorbable suture repair following a posterior approach to the hip joint.
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Sensor-guided Knee Surgery Provides Improved Patient Outcomes and Cost Savings in a 90-day Bundle
Tsun yee Law, MD, MBA, Lorraine Marshall, MSN, ARNP, FNP-BC, Rushabh M. Vakharia, MD, Justin J. Toma, MD, Holy Cross Orthopedic Institute, Fort Lauderdale, FL, Samuel Rosas, MD, PhD, MBA, Wake Forest University School of Medicine, Winston-Salem, NC
1333
In an era when the costs of surgical care are becoming increasingly scrutinized, the introduction of new technologies that may improve clinical outcomes can be limited due to economic constraints. Thus, bundled care payment models have emerged to reduce costs, improve outcomes and increase overall value. Since a bundle is a single reimbursement per episode of care that includes the surgical costs, as well as postoperative care and rehabilitation, cost savings are generally achieved through a reduction of services, complications and/or materials used. The present study demonstrates significant cost savings with a 90-day bundle for sensor-assisted total knee arthroplasty (TKA).
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Identification of the Sensory Dependent Locations of the Shoulder Joint to Optimize Surgical Approaches and Reduce Postoperative Pain: A Systematic Review
Andrew Jae-Min Park MSIV, Loma Linda University Medical School, Redlands, California, Joseph Liu, MD, Loma Linda University Health, Loma Linda, California, Paul Sethi, MD, Orthopaedic and Neurosurgery Specialists, Greenwich, Connecticut, Sean McMillan, DO, Virtua Health System, Cherry Hill, New Jersey , Elizabeth Ford, DO, Inspira Health System, Vineland New Jersey, Michael F. Shepard, MD, Orthopaedic Specialty Institute Medical , Group of Orange County, Orange County, California, Nirav H. Amin, MD, Saint Joseph’s Heritage Health System, Orange, California
1355
Introduction: Treatment of post-surgical pain is predicated by an understanding of pain generators. The purpose of this review is to identify sensory dependent areas of the shoulder and discuss their correlation in treating postoperative pain.
Materials and Methods: Pubmed, Embase, and Cochrane Database of Systemic Reviews were searched (key terms: “Nociception” or “sensory pain receptors” or “pain map” or “neuroanatomy and shoulder” or “rotator cuff”) to identify studies in the current literature (1966–2018) regarding sensory innervation of the shoulder and rotator cuff. The search was limited to the English language, human studies, and publication types to reviews and clinical studies. Articles written in other languages besides English, animal studies, abstracts, and conference notes were excluded. Each search result was investigated for relevant physiological information of the nerve endings and nociceptors as well as pertinent information and figures that illustrated the location of the identified receptors.
Results: A total of 12 articles were identified that addressed the sensory innervation of the shoulder. The shoulder capsule has the highest sensory nerve density. The attachment sites between the labrum and the capsule and glenoid rim were also found to be highly sensory dependent, in contrast to the peri-core zone at the capsulolabral junction, which was found to be less concentrated with fascicles and sensory nerve endings. The subacromial bursa is also a highly sensory dependent structure, with a more concentrated neural network on the coracoacromial side compared to other quadrants of the bursa.
Cutaneous locations of sensory fibers on the shoulder are best defined by mapping the pressure pain threshold (PPT) of various locations on the shoulder. The most sensory dependent locations of the shoulder were found to be the posterior border of the acromion, the glenohumeral joint, the anterior deltoid, and the upper trapezius.
Conclusion: This review examined the origin of pain in the shoulder, the location of cutaneous pain receptors, and receptors in each major part of the shoulder. Providing analgesia to these densely innervated areas of the shoulder can potentially reduce pain associated with surgical trauma. In addition, knowledge of the sensory dependent areas of the shoulder may elicit consideration of alternative incision sites and surgical protocols to decrease the insult to nociceptors in these locations.
These changes could possibly decrease the narcotic requirement in the postoperative period.
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Robotic-Assisted versus Manual Total Knee Arthroplasty in a Crossover Cohort: What Did Patients Prefer?
Jessica N. Pelkowski, DNP, APRN, Benjamin K. Wilke, MD, Assistant Professor, Matthew M. Crowe, MD, Assistant Professor, Courtney E. Sherman, MD, Assistant Professor, Cedric J. Ortiguera, MD, Assistant Professor, Cameron K. Ledford, MD, Assistant Professor, Mayo Clinic, Jacksonville, Florida
1328
Background: Robotic-assisted total knee arthroplasty represents an increasingly utilized surgical technology; however, there remains clinical question whether the technique produces improved clinical and patient-reported outcomes. The purpose of this study was to evaluate early clinical outcomes and patient preference of robotic-assisted total knee arthroplasty (rTKA) versus manual TKA (mTKA) in a direct crossover cohort of patients who underwent consecutive TKAs by each technique.
Materials and Methods: A retrospective chart review and telephone interview was performed on 36 patients who underwent both rTKA and mTKA by a single surgeon between 2012–2018. Perioperative outcomes—complications/reoperations and patient-preferred technique—were collected with mean clinical follow up of 4.8 and 2.0 years for mTKA and rTKA, respectively. Results: mTKA were performed significantly (p<0.01) more quickly than rTKA, including shorter tourniquet time (56 versus 73 minutes) and total operating room time (93 versus 116 minutes). rTKA patients length of stay (LOS) was significantly (p<0.01) decreased (1.8 days) compared to mTKA (2.3 days). For rTKA and mTKA, respectively, there was no difference in final range of motion (119 versus 122 degrees), Visual Analog Scale (1.6 versus 0.9), or Knee Osteoarthritis Outcome Score, Jr (85 versus 87). Twenty (56%) reported rTKA as the preferred technique over mTKA.
Conclusion: In same patient direct comparison, rTKA required longer operative time but improved LOS compared to mTKA. There was no difference in final outcomes with only slightly more patients preferring rTKA.
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Predictors of Functional Outcome After Microfracture Treatment of Cartilage Defects of the Knee
Thomas Neri, MD, PhD, Margaux Dehon, MD, Frederic Farizon, MD, Remi Philippot, MD, PhD, Department of Orthopaedic Surgery, University Hospital Centre of Saint-Etienne, Saint-Etienne, France, Antonio Klasan, MD, Department of Orthopedics and Traumatology, Kepler University Hospital GmbH, Linz, Austria, and Johannes Kepler University Linz, Austria, Sven Edward Putnis, MD, Department of Orthopaedics and Traumatology, Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom
1357
Introduction: Microfracture (MFx) is a widely used technique in the treatment of articular cartilage defects of the knee. The objective of this study was to determine the prognostic factors of functional outcomes after MFx treatment of knee cartilage defects ≤ 4 cm2.
Materials and methods: Forty-eight patients who were to be treated by MFx for knee cartilage defects ≤ 4 cm2 were prospectively included. The mean follow-up was 5.7 years (3.7-9.5). Demographics, sport practiced, time from diagnosis to surgery and associated lesions were collected. The cartilage defect was graded according to the ICRS classification. The MOCART score was calculated from a one-year MRI. The subjective VAS and IKDC scores were collected preoperatively and at the latest follow-up. Prognostic factors were determined using univariate and multivariate regression analyses incorporating pre-, peri- and postoperative clinical and radiological criteria. The dependent variable was defined as the difference between the pre- and post-operative clinical scores (dIKDC and dVAS).
Results: The mean size of the cartilage defect was 1.8 cm² (0.8-4). At the last follow-up, the VAS and IKDC scores were significantly improved compared to the pre-operative period (p<0.01). The average MOCART score on the one-year MRI was 50 (20-70). Three patients (6 %) who demonstrated filling defects on MRI and debilitating pain required surgical re-intervention. The factors that impacted the functional outcome as reflected by the VAS and IKDC scores were age, BMI, time from diagnosis to surgery, size of the lesion and the MOCART score.
Conclusion: This study demonstrates that MFx is a successful first-line treatment option for small articular cartilage defects (≤ 4 cm2) of the knee and provides good function and pain relief in the mid-term. The predictors of poor functional outcomes were older age, higher BMI, longer time from diagnosis to surgery, larger lesion size and lower MOCART score.
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Surgical Tray Optimization and Efficiency: The Impact of a Novel Sealed Sterile Container and Instrument Tray Technology
Kevin B. Marchand, BS, Hytham S. Salem, MD, Michael A. Mont, MD, Chief of Joint Reconstruction, Northwell Health Orthopaedics , Lenox Hill Hospital, New York, New York, Kelly B. Taylor, RN, Robert C. Marchand, MD, South County Orthopaedics, Orthopaedics Rhode Island, Wakefield, Rhode Island
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Introduction: As bundle payments have begun focusing on orthopaedic procedures, particularly total knee arthroplasties (TKAs), surgeons and hospitals have evaluated methods for improving efficiency. Few studies have investigated the impact of novel, sealed-container and instrument-tray technology on turnover and costs. Therefore, the purpose of this study was to compare traditional and sealed container-sterilized TKA surgical trays by: 1) investigating the setup and clean-down time in the operating room (OR); 2) examining trays processing time in central sterile supply (CS); and 3) estimating OR and CS costs and waste produced.
Materials and Methods: An interdisciplinary team determined points throughout a TKA tray single-case life cycle that could cause variations in turnover time. The times were recorded for two different TKA tray configurations. Process A utilized instruments housed in vendor trays that were “blue” wrap sterilized, while Process B employed optimized trays that were sealed container-sterilized. Times were recorded during preoperative setup and postoperative clean down in the OR and CS. Reductions in mean OR or CS times were used to estimate cost savings. Wastes were analyzed for each method. Statistical analyses using Student t-tests were used to determine statistical differences and a p-value of less than 0.05 was considered significant.
Results: Overall, the use of optimized trays and sealed sterilization containers reduced the turnover time by 57 minutes and the number of trays by a mean of three. OR and CS processing yearly savings were estimated to be $249,245. Waste disposal was an estimated 10,590 ounces and 450 ounces for traditional and sealed containers, respectively.
Conclusion: Novel sealed sterilization containers demonstrated increased efficiency in the total turnover time of TKA trays. This is important for surgeons participating in bundle payments who perform surgery in a hospital and ambulatory surgery center. Reduced turnover time could potentially increase case load and decrease the need for extra instrumentation or loaner trays. This simple means of increasing efficiency could be used as a model for surgeons wishing to streamline surgical trays and reduce costs.
Dual Mobility Acetabular Systems for Total Hip Arthroplasty: A Multicenter Study and Technique Report
Hytham S. Salem, MD, Michael A. Mont, MD, Vice President of Strategic Initiatives, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Steven F. Harwin, MD, Total Hip and Knee Arthroplasty, Mount Sinai West Hospital, New York, New York, Geoffrey H. Westrich, MD, Adult Reconstruction , Hospital for Special Surgery, New York, New York, Ronald E. Delanois, MD, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Dual mobility constructs for THA have been a tremendous advancement for hip arthroplasty surgeons, especially in scenarios where instability is a possibility. While some researchers have reported events of malseating with their use, the authors of the current study believe that this may be avoided by ensuring appropriate surgical technique. Therefore, the purpose of this study was to: (1) describe the surgical techniques that we employ to ensure that the liner is adequately seated; and (2) report the rates of malseating, dislocation, and aseptic loosening among our collective cohort of dual mobility THA patients.
Materials and Methods: All patients who underwent THA with a dual mobility construct between January 1, 2010 and December 31, 2018 at four institutions were identified. Those who had less than two years of follow up were excluded. Outcomes of interest included radiographic evidence of liner malseating, aseptic loosening, and dislocation. A total of 1,826 patients who underwent THA with a dual mobility construct were identified. Among these patients, 504 had less than two years of follow up and were excluded from our analysis. The remaining 1,322 patients met our criteria including 941 primary THAs (71.2%) and 381 revision THAs (28.8%).
Results: After a minimum follow-up period of two years, there were only two cases of malseated liners (0.15%). Serial follow ups have demonstrated no movement or changes in the position of the liners over time for both patients. In addition, they have been shown to have normal serum metal ion levels and no clinical complaints after 5.3- and 7.1-year follow up. Seven of 1,322 patients (0.53%) experienced a dislocation. Aseptic loosening of the acetabular cup was diagnosed in one patient 3.4 years postoperatively. In three patients, femoral component loosening occurred after a mean follow-up period of 2.3 years, (1.3 to 3.1 years). Among the 941 primary cases, the incidence of liner malseating was 0.21%, as both patients who experienced this complication were in this subgroup. As stated above, these patients have demonstrated normal serum metal ion levels and no clinical or radiographic sequelae as a result of the liner malseating. The dislocation rate among primary cases was 0.21% (2 of 941). Aseptic loosening of the acetabular component occurred in two (0.21%) while one patient (0.1%) was found to have femoral component loosening at final follow up. Of the 381 revision THAs, there were no cases of liner malseating. Five revision THA patients (1.3%) experienced a dislocation over our study period. Two revision THA patients experienced aseptic loosening of the femoral component (0.79%) at final follow up.
Conclusions: The results of this paper demonstrate that malseating is not a prevalent issue with dual mobility THA when appropriate surgical techniques are used. It is hoped that that this paper clarifies the techniques for implantation of these implants and that excellent results can be achieved when care is taken to ensure that liners are well-seated intraoperatively. .
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The Evolution of Cryoneurolysis for the Treatment of Shoulder, Hip, and Knee Pain: Where Are We Now and Where Will We Go? A Systematic Review
Sean McMillan, DO, Virtua Health System, Cherry Hill, New Jersey, Thomas Dwyer, MD, Elizabeth Ford, DO, Inspira Health System, Vineland, New Jersey, Nirav H. Amin, MD, Saint Joseph’s Heritage Health System, Orange, California
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Cryoneurolysis, otherwise known as cryoanalgesia, is a process of addressing nerve-related pain via disruption of nerve conduction utilizing extreme cold temperatures. Throughout the literature, cryoneurolysis has been described for decades across various specialties. Within the past few years, a growing movement of its application within orthopedics has provided pain relief solutions in both the non-surgical and surgical space. A review of the literature utilizing multiple medical search engines was performed to identify relevant orthopedic articles related to the treatment of joint pain with cryoneurolysis or cryoanalgesia. A review of the cryoneurolysis, indications, efficacy, and treatment gaps within the literature were identified to provide guidance for future research.
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An Economic Evaluation of Over 200,000 Revision Total Hip Arthroplasties: Is the Current Model Sustainable?
William DeGouveia, BS, MS, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, Hytham S. Salem, MD, Zhongming Chen, MD, Michael A. Mont, MD, Northwell Health Orthopaedics , Lenox Hill Hospital, New York, New York, Nipun Sodhi, MD, Long Island Jewish Medical Center, Northwell Health, New York, New York, Hiba K. Anis, MD, Cleveland Clinic, Cleveland, Ohio, Rushabh Vakharia, MD, Maimonides Medical Center, New York, New York, Martin W. Roche, MD, Orthopedic Research Institute, Holy Cross Hospital, Ft. Lauderdale, Florida, Michael A. Mont, MD, Northwell Health Orthopaedics , Lenox Hill Hospital, New York, New York
1347
Introduction: Revision total hip arthroplasties (rTHAs) are typically more complicated than primaries and may have a greater economic burden. To date, the current economic model supporting these procedures has not been evaluated. Therefore, the purpose of this study was to determine the 10-year temporal changes in charges, reimbursement rates, and net losses in patients undergoing an rTHA utilizing a large, nationwide database.
Materials and Methods: A query was performed from 2005 to 2014 to identify patients who underwent rTHA. Analyzed outcomes included trends in costs of care, reimbursement rates, and net losses per annum within the last 10 years. Charges are defined as those by the provider to the insurance company, whereas, reimbursements were those payments received from the insurance company. Net losses were calculated as the difference in charges from reimbursement rates.
Results: Total charges increased from $1,119,725,881 in 2005 to $2,066,842,547 in 2014. Total reimbursements increased from $287,461,852 in 2005 to $478,430,569 in 2014. Per patient charges increased 67.4% from 2005 to 2014 and from $51,963.18 in 2005 to $86,791.07 in 2014. There was an increase in reimbursement per patient of 61.4% from $12,450.70 in 2005 to $20,090.31 in 2014. Net losses increased 68.80%, from $39,512.48 to $66,700.76 from 2005 to 2014.
Conclusion: This study indicates substantial increases in charges and reimbursements over a 10-year period for patients undergoing rTHA. However, reimbursement increased at a lower rate than that of charges, resulting in major net losses. This study highlights the need to reevaluate the economic models behind rTHA for longer-term sustainment.
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Robotic-Assisted versus Manually Implanted Total Hip Arthroplasty: A Clinical and Radiographic Comparison
Christopher J. Hadley, BS, Eric L. Grossman, MD, Rothman Orthopaedic Institute, Jefferson University Hospital, Philadelphia, Pennsylvania, Michael A. Mont, MD, Hytham S. Salem, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Fabio Catani, MD, Andrea Marcovigi, MD, University of Modena, Modena, Italy
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Introduction: Component positioning during THA is one of the more critical surgeon-controlled factors as malposition has been associated with higher rates of hip dislocations, poor biomechanics, accelerated wear rates, leg length discrepancies (LLDs), and revision surgeries. In order to reduce the rates of component malposition and improve surgical accuracy, robotic-assisted THA has developed increased interest. The primary objective of this study was to compare patient outcomes following THA using the Mako Stryker robotic system (Stryker Orthopaedics, Mahwah, New Jersey) to outcomes in patients who underwent conventional instrumented THA.
Materials and Methods: Consecutive patients undergoing THA with a direct-lateral surgical approach from a single surgeon were reviewed. Patients were treated with either a robotic-arm assisted total hip arthroplasty (RTHA) or a conventional-instrumented total hip arthroplasty (CTHA). Minimum follow up was 16 months.
Results: Robotic-assisted THA significantly improved patient outcomes compared to conventional THA. No significant differences were observed in postoperative radiographic outcomes between the RTHA and CTHA cohorts. In our analysis, patients in the RTHA cohort compared to the CTHA cohort had significantly higher Western Ontario and McMaster Universities Arthritis Index (WOMAC) (P<0.001) and Harris Hip Scores (P<0.05) at final follow up. There were no significant differences between the RTHA cohort and CTHA cohorts in regard to cup inclination (°) (P=0.10), hip length difference (mm) (P=0.80), hip length discrepancy (mm) (P=0.10), and global offset difference (mm) (P=0.20).
Conclusion: Further studies, particularly prospective randomized studies, are necessary to investigate the short- and long-term clinical outcomes, possible long-term complications, and cost-effectiveness of robotic-assisted THA in regard to improving outcomes and accuracy.
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Ileus, Gastrointestinal Bleeding and Clostridium difficile Colitis after Hip and Knee Replacement - a Systematic Review
Antonio Klasan, MD, Kepler University Hospital GmbH, Linz, Austria, and Johannes Kepler University Linz, Austria, Sven Edward Putnis, MD, Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom., Thomas Jan Heyse, MD, PhD, Orthomedic Frankfurt Offenbach, Offenbach, Germany, Goran Madzarac, MD, University Hospital Zagreb, Center for Lung Diseases, Zagreb, Croatia, Tobias Gotterbarm, MD, Kepler University Hospital GmbH, Linz, Austria, and Johannes Kepler University Linz, Austria, Thomas Neri, MD, PhD, University Hospital Centre of Saint-Etienne, Saint-Etienne, France, Inter-University Laboratory of Human Movement Science, University Lyon - University Jean Monnet Saint Etienne, France
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Introduction: Major gastrointestinal complications after arthroplasty are rare, but can have detrimental effects on the patient and can substantially increase the overall cost of treatment. This systematic review provides an overview of ileus, gastrointestinal bleeding and C. difficile colitis after total hip and knee arthroplasty.
Materials and methods: We followed the PRISMA guidelines and searched 3 databases for the period between 1 January 2000 and 31 December 2018. The manual search included references in retrieved articles. We extracted data on the cohort size, study level, arthroplasty procedure, complications and their incidence, and recommendations by the study.
Results: Twenty-five studies that analyzed these complications after total knee arthroplasty (TKA) and total hip arthroplasty (THA) were identified. These complications have an incidence of up to 2% each. According to some of the studies, an incidence of 0% is possible. While the risk factors for ileus varied greatly, those for C. difficile colitis were more consistent. There are some recommendations for reducing the incidence of ileus and C. difficile. This heterogeneity does not allow us to draw any conclusion regarding which thromboprophylaxis agent has the lowest incidence of gastrointestinal bleeding.
Conclusion: The complications investigated in this systematic review are rare and have a reported incidence of up to 2% each. Even though there are some recommendations for reducing the complication rate, due to the complex nature of the arthroplasty setting, there is a need for further investigation of these risk factors and how they can be reduced.
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Can Preoperative Factors Be Used to Determine Optimal Implant Design for Total Knee Arthroplasty?
Hany S. Bedair, MD , Assistant Professor of Orthopaedic Surgery (HMS), Christopher M. Melnic, MD, Akhil Katakam, MBA, Harvard Medical School, Boston, Massachusetts, Philip Aurigemma, MD, Maureen K. Dwyer, PhD, Newton-Wellesley Hospital, Newton, Massachusetts
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Introduction: Although studies have demonstrated similar outcomes between ultracongruent (UC) and traditional bearings, debate exists regarding the optimum bearing surface. We sought to determine whether preoperative factors may predict use of a UC bearing when compared to a standard cruciate retaining (CR) group.
Materials and Methods: The study cohort consisted of 117 patients who underwent primary total knee arthroplasty (TKA). The implants utilized were either the CR or UC polyethylene components of the Zimmer Persona® Total Knee System. Patient demographics and comorbidities were documented. Intraoperative variables and postoperative outcomes were recorded. We calculated change in tibial slope and femoral condylar offset from pre- to post-surgery and computed the percentage of patients for whom an increase in tibial slope or femoral condylar offset was determined. All dependent variables were compared between patients who received the UC component and those with a CR component using either independent samples t-tests or chi-square test of independence.
Results: Thirty-nine patients received a UC insert and 78 patients received a CR insert. Mean length of stay (p=0.017), estimated blood loss (p=0.021), and tourniquet time (p=0.032) were greater for the UC group. Intraoperative implant variables were not different between the groups. However, the proportion of patients for whom tibial slope increased postoperatively was greater for the UC group compared to the CR group (p=0.018).
Conclusion: Our results showed that no preoperative medical comorbidities or demographic factors predicted use of the UC bearing; however, postoperative tibial slope was increased for a greater number of patients who received the UC implant.
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Estimation of Femoral Version During Total Hip Arthroplasty: Surgeon Visual Assessment versus Robotic-Arm Assisted Technology
Robert C. Marchand, MD, Ortho Rhode Island, Wakefield, Rhode Island, Shannon Collins, BS, Stryker Orthopaedics, Mahwah, New Jersey, Kevin B. Marchand, BS, Hytham S. Salem, MD, Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
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Introduction: Malposition of THA implants can lead to many complications, some of which may necessitate reoperation. Thus, proper implant placement is critical for optimizing patient outcomes. In addition, intraoperative visual estimation of stem position has been shown to be unreliable. Therefore, the purpose of this study was to compare a surgeon’s visual estimation of femoral version to the actual version captured using a three-dimensional robotic-arm assisted platform.
Materials and Methods: A prospective study of 25 THAs performed by a single surgeon was performed. The mean version, as estimated by intraoperative visual assessment, was compared to that measured by the robotic-arm assisted technology software using a two-sided t-test. Outliers were evaluated for the following intervals: 1 to 5°, 6 to 10°, and greater than 10°. A separate analysis was performed for anteverted versus retroverted stems. Results: The mean version, as estimated by intraoperative visual assessment, was 9.16 ± 4.02° (range, 3 to 18°) compared to 3.52 ± 8.66° (range, -12 to 19) as measured by the robotic-arm assisted software (P=0.005). The surgeon’s estimates of broach version and those measured by the robotic-arm assisted software were identical in three cases (12%). The evaluation methods differed by 1 to 5° in six cases (24%), 6 to 10° in 10 cases (40%), and greater than 10° in six cases (24%). Larger differences between methods were noted for cases in which the stem was found to be in anteversion by the robotic-arm assisted software.
Conclusions: Visual estimation of femoral implant version differed significantly from measurements captured by three-dimensional robotic-arm assisted imaging. This suggests that estimating stem position intraoperatively by eye is not reliable, even when done by an experienced surgeon. The use of robotic-arm assisted technology may be recommended for determining femoral stem version intraoperatively.
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Evolution of 3-Dimensional Functional Planning for Total Hip Arthroplasty with a Robotic Platform
Matthew S. Hepinstall, MD, NYU Langone Health , New York, New York, Brandon Naylor, DO, Hytham S. Salem, MD, Michael A. Mont, MD, Northwell Health, Lenox Hill Hospital, New York, New York
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Robotic-assisted surgery was introduced to make various mechanical aspects of a total hip arthroplasty more reproducible. When paired with sophisticated three-dimensional preoperative planning, robotic surgery offers the promise that a surgeon might select and reliably achieve targets for component position to optimize hip center-of-rotation, acetabular anteversion and inclination, femoral offset, as well as limb length. This paper describes a patient-specific step-by-step approach to performing these procedures including taking into account pelvic tilt. It is hoped that these described techniques will further optimize robotic-assisted hip arthroplasty procedures.
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