Surgical Technology International
38th Edition
Contains 63 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
June 2021 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Excellent Clinical and Radiographic Outcomes with Direct Superior Total Hip Arthroplasty with a Minimum of Two-Year Follow Up
Moritz J. Sharabianlou Korth, MD, Rami Ezzibdeh, MSc, Prerna Arora, M.Tech, Derek F. Amanatullah, MD, PhD, Assistant Professor, Stanford Medicine, Redwood City, California
1336
This study aims to establish the midterm safety and performance for the direct superior approach to minimally invasive surgery total hip arthroplasty (MIS-THA). We used a unicentric, single-surgeon, retrospective, consecutive case series analysis of the first 40 patients who received primary unilateral direct superior MIS-THA. Special attention was given to functional recovery by measuring Harris Hip Score (HHS) and timed-up-and-go (TUG) with a mean follow up of 2.2 ± 0.4 years. A radiologic evaluation was performed. HHS and TUG improved significantly at three months and one year (p < 0.001). All components were placed within the Lewinnek safe zone with no change position or signs of loosening at two years. With a minimum of two years of follow up, the direct superior approach appears to be safe without any obvious or consistent postoperative complications—clinically or radiographically—with excellent functional recovery. Additionally, our subgroup analysis supported no late learning curve effect.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Robotic-Arm Assisted Direct Anterior Total Hip Arthroplasty; Improving Implant Accuracy
Sheng Xu MBBS, MRCS, Lawrence Irving Calderon Bernardo, MD, Khye Soon Andy Yew, PhD, Hee Nee Pang MBBS, Med, FRCS, Singapore General Hospital, Outram, Singapore
1368
Introduction: The aim of this study was to investigate the accuracy of implant position of robotic-arm assisted total hip arthroplasty (THA) via the direct anterior approach (DAA).
Materials and Methods: All patients who underwent robotic-arm assisted DAA THA (MAKO Surgical Corp., Ft. Lauderdale, Florida) from November 2018 to January 2020 were prospectively followed up. Pelvis indices (limb length discrepancy, femoral and hip offset, implant inclination, and anteversion), surgical duration, length of stay, and complications were recorded. To further evaluate the accuracy of robotic-arm assisted THA, patients who underwent manual DAA THA by the same surgeon were match-paired with the study group.
Results: Twenty-five patients underwent robotic-arm assisted DAA THR. Limb length discrepancy was restored to 0.1mm (±3.4mm) from 10.0mm (±6.4mm) postoperatively. Preoperatively, the difference in femoral offset was 5.1mm (±5.1mm), and this was corrected to 1.9mm (±6.5mm) postoperatively.
Nine cases had target inclination of 40° and mean inclination achieved was 40.7° (±0.9°). Sixteen cases had target inclination of 45° and mean inclination achieved was 45.3° (±1.0°). Mean anteversion was 19.5° (±2.4°).
Propensity matched analysis showed that the root mean square errors for manual cup implantation compared to the robotic-arm assisted group was 2.3 times higher for anteversion and 6.3 times higher for inclination. Fourteen (56%) of the cups were within Callanan safe-zone and 18 (72%) within Lewinnek safe-zone in the manual group compared to 18 (72%) and 25 (100%), respectively, in the robotic-arm assisted group.
Conclusion: Combining the muscle-sparing technique of DAA with the improved implant placement with the robotic-arm assisted platform is a promising solution to improving THA outcomes.
Order Digital ePrint:
PDF Format - $115.00
1 Year Subscription
including this article:
Online PDF - $399.00
Case-Controlled Analysis of the Direct Superior and Mini-Posterior Approach for Total Hip Arthroplasty at a Minimum of Two Years of Follow Up
Rami Ezzibdeh, MSc, Moritz J. Sharabianlou Korth, MD, Prerna Arora, M.Tech, Derek F. Amanatullah, MD, PhD, Assistant Professor, Stanford University, Redwood City, California
1381
Introduction: The direct superior approach to total hip arthroplasty (THA) is a recently developed technique aimed at sparing the iliotibial band, obturator externus tendon, and quadratus femoris muscle while working within the familiar anatomical landscape of the posterior approach. While the direct superior approach has been used for more than a decade, there is a lack of midterm outcomes and safety data. This study elaborates on promising short-term results and aims to investigate the midterm outcomes of the direct superior approach. Materials and Methods: We present a unicentric, retrospective case-controlled analysis of a minimum two-year follow up of the direct superior approach in comparison to those of the more conventional and established mini-posterior approach. Results: The results indicate that patient recovery, as measured by Harris Hip Score and timed-up-and-go at three months and two years, are virtually identical. There was no difference in gait aid utilization or frequency of narcotic use. However, there was a statistically significant reduction in length of stay by over one day associated with the direct superior approach (p=0.003). There was no compromise in acetabular component position or observed lucencies over time. Conclusion: Overall, the direct superior approach appears to be safe and warrants longer-term study to evaluate its effect on hospital-related cost, same-day discharge, and hip stability.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
A Novel Biofilm-Disrupting Wound Care Technology for the Prevention of Surgical Site Infections Following Total Joint Arthroplasty: A Conceptual Review
Hytham S. Salem, MD, Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
1447
Surgical site infections (SSIs) are a major driver for increased costs following lower extremity joint arthroplasty procedures. It has been estimated that these account for over $2 billion in annual costs in the United States. While many of the current strategies for the prevention and treatment of SSIs target planktonic bacteria, 80 to 90% of bacterial pathogens exist in a sessile state. These sessile bacteria can produce extracellular polymeric substance (EPS) as protective barriers from host immune defenses and antimicrobial agents and thus, can be exceedingly difficult to eradicate. A novel wound care gel that disrupts the EPS and destroys the inciting pathogens has been developed for the treatment and prevention of biofilm-related infections. This is achieved by the simultaneous action of four key ingredients: (1) citric acid; (2) sodium citrate; (3) benzalkonium chloride; and (4) polyethylene glycol. Together, these constituents create a high osmolarity, pH-controlled environment that deconstructs and prevents biofilm formation, while destroying pathogens and promoting a moist environment for optimal wound healing. The available clinical evidence demonstrating the efficacy of this technology has been summarized, as well as the economic implications of its implementation and the authors’ preferred method of its use. Due to the multifaceted burden associated with biofilm-producing bacteria in arthroplasty patients, this technology may prove to be beneficial for patients who have higher risks for infection, or perhaps, as a prophylactic measure to prevent infections for all patients.
Order Digital ePrint:
PDF Format - $129.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Diagnosis and Treatment of Femoral Head Osteonecrosis: A Protocol for Development of Evidence-Based
Clinical Practice Guidelines
Edward Y. Cheng, MD, Professor of Orthopaedic Surgery, Caitlin Bakker, MLIS, University of Minnesota Minneapolis, Minnesota, Quanjun Cui, MD, Professor of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, Stuart B. Goodman, PhD, MD, Professor of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California Wataru Ando, MD, PhD, Professor of Orthopaedic Surgery, Nobuhiko Sugano, MD, PhD, Professor of Orthopaedic Surgery, Osaka University, Osaka, Japan, Seung-Hoon Baek, MD, PhD, Professor of Orthopaedic Surgery, Shin-Yoon Kim, MD, PhD, Professor of Orthopaedic Surgery, Kyungpook National University, Daegu, South Korea, Wolf Drescher, MD, Professor of Orthopaedic Surgery, RWTH Aachen University, Aachen, Germany, Philippe Hernigou, MD, Professor of Orthopaedic Surgery, Hôpital Henri Mondo Paris, France, Lynne C. Jones, PhD, Professor of Orthopaedic Surgery, Johns Hopkins University Baltimore, Maryland, Harry Kim, MD, Professor of Orthopaedic Surgery, Scottish Rite for Children, Dallas, Texas Tae-Young Kim, MD, PhD, Professor of Orthopaedic Surgery, Konkuk University Medical Center Seoul, South Korea, Yong-Chan Ha, MD, Professor of Orthopaedic Surgery, Chung-Ang University, Seoul, South Korea Kyung-Hoi Koo, MD, Professor of Orthopaedic Surgery, Seoul National University, Seoul, South Korea, Mel S. Lee, MD, PhD, Professor of Orthopaedic Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Michael A. Mont, MD, Chief of Joint Reconstruction Vice President of Strategic Initiatives, Northwell Health Orthopaedics, Hytham S. Salem, MD, Research Fellow, Lenox Hill Hospital New York, New York, Ines Reichert, MD, PHD, Professor of Orthopaedic Surgery, Kings College Hospital London, London, United Kingdom, Takashi Sakai, MD, Professor of Orthopaedic Surgery, Yamaguchi University Hospital, Ube, Japan, Rafael J. Sierra, MD, Mayo Clinic, Rochester, Minnesota, Ben Stronach, MD, Professor of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi, Takuaki Yamamoto, MD, Professor of Orthopaedic Surgery, Fukuoka University, Fukuoka, Japan Byung-Ho Yoon, MD, PhD, Professor of Orthopaedic Surgery, Ewha Womans University Seoul, South Korea Dewei Zhao, MD, Profeessor of Orthopaedic Surgery, Zhongshan Hospital of Dalian University Dalian, China
1437
Introduction: There are many treatment options for patients who have osteonecrosis of the femoral head (ONFH) and management strategies vary widely both among and within individual countries. Although many researchers have attempted to elucidate the optimal strategies for managing this disease, the lack of large-scale randomized control trials and the lack of agreement on disease staging have curtailed the development of clear-cut guidelines.
Materials and Methods: The Association Research Circulation Osseous (ARCO) group sought to address three questions for the management of patients who have ONFH: 1) What imaging studies are most sensitive and specific for the diagnostic evaluation of patients who have ONFH?; 2) What is the best treatment strategy for preventing disease progression in patients who have pre-collapse lesions?; and 3) What is the best treatment strategy for patients who have post-collapse disease? The Patient, Intervention, Comparison, and Outcome (PICO) format was used to formulate the search strategy for each research question. A systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ARCO participants have been allocated to three groups, each representing one of the PICO questions. After qualitative and quantitative analysis of the data extracted from studies pertaining to each of the three research questions, a set of evidence-based clinical practice guidelines will be proposed for the management of patients who have ONFH.
Discussion: It is not always clear which treatment method is optimal for the management of ONFH. Thus, many surgeons have developed and performed various procedures based on patient-specific factors. As there is no consensus on the optimal treatment for various stages of disease, it was clear that developing evidence-based clinical practice guidelines would provide more structure and uniformity to management of these patients. Therefore, the results of this systematic review will lead to the development guidelines that may improve patient-care strategies and result in better outcomes for patients who have ONFH.
Order Digital ePrint:
PDF Format - $135.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Patient-Specific Implants for Focal Cartilage Lesions in The Knee: Implant Survivorship Analysis up to Seven Years Post-Implantation
Leif Ryd, MD, Episurf Medical, Stockholm, Sweden, Katarina Flodström, PhD, Episurf Medical, Stockholm, Sweden, Michael T. Manley, FRSA, PhD, Michael T. Manley FRSA, PhD, LLC, Naples, FL, USA
1384
In the quest for increased surgical precision and improved joint kinematics, Computer-Assisted Orthopedic Surgery (CAOS) shows promising results for both total and partial joint replacement. In the knee, computer-assisted joint design can now be applied to the treatment of younger patients suffering pain and restriction of activity due to focal defects in their femoral articular cartilage. By taking MRI scans of the affected knee and digitally segmenting these scans, we can identify and map focal defects in cartilage and bone. Metallic implants matched to the defect can be fabricated, and guide instrumentation to ensure proper implant alignment and depth of recession in the surrounding cartilage can be designed from segmented MRI scans.
Beginning in 2012, a series of 682 patient-specific implants were designed based on MRI analysis of femoral cartilage focal defects, and implanted in 612 knees. A Kaplan-Meier analysis found a cumulative survivorship of 96% at 7-year follow-up from the first implantation. Fourteen (2.3%) of these implants required revision due to disease progression, incorrect implant positioning, and inadequate lesion coverage at the time of surgery.
These survivorship data compare favorably with all other modes of treatment for femoral focal cartilage lesions and support the use of patient-specific implants designed from segmented MRI scans in these cases.
All-Inside Arthroscopic Repair for Longitudinal Meniscal Tears: Clinical and Functional Results
Stefano Grossi, MD, Matteo Ceccoli, MD, Unità Operativa di Ortopedia e Traumatologia, Ospedale di Cecina, Usl Toscana Nord Ovest, Cecina, Italy, Edoardo Ipponi, MD, Eric Bufalino, MD, Gabriele Gariffo, MD, Gabriele Filoni, MD, Matteo Simonetti, MD, Gianluca Ciapini, MD, Michelangelo Scaglione, MD, Associate Professor, Dipartimento di Chirurgia Traslazionale e Nuove Tecnologie, Clinica Ortopedica I, Azienda Ospedaliero Universitaria Pisana, Cisanello, Università di Pisa, Pisa, Italy
1396
Meniscal injuries are a common challenge in orthopaedic surgery. Depending on their location and the patient’s age and functional needs, they can be treated either conservatively or surgically. A surgical approach can consist of arthroscopic meniscectomy or meniscal suture. The latter is the treatment of choice in case of lesions involving the red-red or red-white areas of the meniscus, especially for young high-demanding patients. We report here our experience with the repair of longitudinal meniscal tears using the all-inside technique with the Fast-Fix™ 360 Meniscal Repair System (Smith & Nephew Endoscopy, Andover, MA). We retrospectively evaluated 20 consecutive cases of longitudinal meniscal tears. In 4 cases, concomitant ACL rupture was diagnosed and treated alongside the meniscal repair. All patients underwent periodic clinical evaluations. At the latest check-up, their functional outcomes were rated according to the Tegner-Lysholm Knee and KOOS scoring scales. The mean Tegner-Lysholm Knee score was 84.85 (44-100) and the mean KOOS score was 88.58. No failure or major complications were observed. Furthermore, a negative statistical association was observed between age at surgery and the post-operative Tegner-Lysholm Knee score (coef. = -1.01189 [-1.942073,-0.0817063], p = 0.035). This relation, independent of gender, meniscus involved, eventual associated ACL reconstruction, and chondral injury, suggests that functional outcomes worsen with increasing patient age. Our results suggest that the arthroscopic all-inside suture is both safe and effective in cases of longitudinal meniscal tear, considering the good post-operative functionality and low rates of local complications and surgical failures.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
A New Additive-Manufactured Cementless Highly Porous Titanium Acetabular Cup for Primary Total Hip Arthroplasty—Early Two-Year Follow Up
Mohammad S. Abdelaal, MD, Ilan Small, BS, William J. Hozack, MD, Professor, Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, Camilo Restrepo, MD, Clinical Research Department, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania,
1398
Introduction: Additive-manufacturing technologies are increasingly being used, not only to create acetabular components with porous coating architecture very similar to the complex trabecular structure of cancellous bone, but also for producing the entire implant in a single step. The aim of this study is to assess two-year clinical and radiological outcomes of a new additive-manufactured cup in primary total hip arthroplasty (THA).
Materials and Methods: We reviewed 266 primary THAs (254 patients) performed in our institution between December 2016 and December 2018 using a new highly porous titanium acetabulum shell fabricated via additive manufacturing. Clinical and functional outcomes were measured using SF/VR-12 and HOOS JR to determine patient satisfaction with surgery. Radiographs were assessed to determine the presence of migration, radiolucency, and loosening. Patients records were reviewed to assess cup survivorship in terms of all-cause revisions and revision for aseptic cup loosening.
Results: At a minimum of two-year follow up (range: 2–3.45 years), the patient cohort demonstrated significant improvement in postoperative functional scores (hip disability and osteoarthritis outcome score for joint replacement [HOOS JR.] and clinical scores (12-item short-form health survey [SF/VR-12]) (p<0.001). One cup developed progressive radiolucent lines at the prosthesis-bone interface consistent with loosening and was revised. The overall acetabular component two-year survivorship free of all-cause failure was 97.4% (95% confidence interval [CI]: 95.5–99.4%). When aseptic loosening of the acetabular component was used as the failure endpoint, the two-years survivorship rate was 99.6% (95% CI: 98.9–100%).
Conclusion: Highly porous titanium cementless acetabular cups produced via additive-manufacturing showed promising early clinical and radiological results in primary THA with low rates of aseptic loosening. Further follow-up studies are needed to assess the long-term survivorship and outcomes of this new acetabular component.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Range of Motion to Impingement Curves Create a New Patient-Specific Impingement-Free Zone for Acetabular Cup Placement
Thomas F. McCarthy, BS, MBA, Matthew T. Thompson, MS, Jim Nevelos, PhD, Implant and Robotics Research, Stryker Orthopaedics, Mahwah, New Jersey, Hytham S. Salem, MD, Brandon H. Naylor, DO, Michael A. Mont, MD, Northwell Health, Lenox Hill Hospital, New York, New York
1399
Introduction: The acetabular “safe zone” has recently been questioned as a reliable reference for predicting total hip arthroplasty impingement and instability as many dislocations occur within the described parameters. Recently, an improved understanding of spino-pelvic mechanics has provided surgeons useful information to both identify those at a higher risk of dislocation and, in some cases, allows altering component positioning to accommodate the patient’s individual “functional” range of motion. The purpose of this study was to create a new patient-specific impingement-free zone by considering range of motion (ROM) to prosthetic impingement for both high flexion and extension poses, thus demarcating a zone that avoids both anterior and posterior impingement, thereby creating an objective approach to identifying a patient’s ideal functional safe zone.
Materials and Methods: A validated hip ROM three-dimensional simulator was utilized to create ROM-to-impingement curves for both high flexion as well as pivot and turn poses. The user imported a computerized tomography (CT) with a supine pelvic tilt (PT) value of zero and implant models (tapered wedge stem, 132° neck angle, 15° stem version, 36mm femoral head). Femur-to-pelvis relative motions were determined for three upright seated poses (femur flexed at 90° and 40° internal rotation, with 0°, 10°, and 20° posterior PT), one chair rise pose (femur flexed at 90° and 0° internal rotation, with the pelvis flexed anteriorly until the pelvis made contact with the femur), and three standing pivot and turn poses (femur set at 5° extension, and 35° external rotation, with 5° posterior PT, 0°, and 5° anterior PT). ROM-to-impingement curves for cup inclination versus anteversion were graphed and compared against the Lewinnek safe zone.
Results: The ROM-to-impingement curves provide an objective assessment of potential impingement sites as they relate to femoral rotation and pelvic tilt. The area between the stand and sit curves is the impingement-free area. A sitting erect pose with a simulated stiff spine (0° PT) yielded less impingement-free combinations of cup inclination and version than poses with greater than 0° posterior pelvic tilt.
Conclusion: The results demonstrate that the acetabular target zone has a relatively small margin for error between the sitting and standing ROM curves to impingement. Importantly, anterior and posterior pelvic tilt can markedly increase the risk of impingement, potentially leading to posterior or anterior dislocations, respectively. This study highlights the importance of correctly identifying the patient-specific functional range of motion to execute optimal component positioning.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Amniotic Stem Cell-Conditioned Media for the Treatment of Nerve and Muscle Pathology: A Systematic Review
Chukwuweike Gwam, MD, MBA, Nequesha Mohamed, MD, Johannes Plate, MD, PhD, Xue Ma, MD, PhD, Wake Forest Baptist Health, Medical Center Boulevard Winston-Salem, North Carolina, Ahmed K. Emara, MD, Noor Chughtai, Cleveland Clinic Foundation, Cleveland, Ohio
1387
Muscle and nerve tissue damage can elicit a significant loss of function and poses as a burden for patients and healthcare providers. Even for tissues, such as the peripheral nerve and skeletal muscle, that harbor significant regenerative capacity, innate regenerative processes often lead to less than optimal recovery and residual loss of function. The reasons for poor regeneration include significant cell damage secondary to oxidative stress, poor recruitment of resident stem cells, and an unfavorable microenvironment for tissue regeneration. Stem cell-based therapy was once thought as a potential therapy in tissue regeneration, due to its self-renewal and multipotent capabilities. Early advocates for cellular-based therapy pointed to the pluripotent nature of stem cells, thus eluding to its ability to differentiate into resident cells as the source of its regenerative capability. However, increasing evidence has revealed a lack of engraftment and differentiation of stem cells, thereby pointing to stem cell paracrine activity as being responsible for its regenerative potential. Stem cell-conditioned media houses biomolecular factors that portray significant regenerative potential. Amniotic-derived stem cell-conditioned media (AFS-CM) has been of particular interest because of its ease of allocation and in vitro culture. The purpose of this review is to report the results of studies that assess the role of AFS-CM for nerve and muscle conditions. In this review, we will cover the effects of AFS-CM on cellular pathways, genes, and protein expression for different nerve and muscle cell types.
Order Digital ePrint:
PDF Format - $125.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Validation of a Virtual Reality Simulator for Percutaneous Pedicle Screw Insertion
Alexander Charalambous, MBChB, BSc, FRCS (Tr&Orth), Neil Segaren, MBBS, FRCS (Tr&Orth), Anil Haldar, MBBS, MRCS, Kalpesh R. Vaghela, MBBS, BSc, MSc, FRCS (Tr&Orth), Syed Aftab, MA, Cantab MBChB, FRCS (Tr&Orth), MSc, Alexander Montgomery, MBChB, FRCS (Tr&Orth), Kashif Akhtar, MBBS, Med, MD, FRCS (Tr&Orth), Joshua K Lee, MBChB, MSc, FRCS (Tr&Orth), The Royal London Hospital, Barts Health NHS Trust, London, UK
1365
Introduction: Working-hour restrictions, rota gaps and an increasing drive for theatre efficiency have resulted in challenges to surgical training. As a result, Virtual Reality (VR) has emerged as a popular tool to augment this training. Our aim was to evaluate the validity of a VR simulator for performing percutaneous pedicle screw guidewire insertion. Materials and Methods: Twenty-four participants were divided into three equal groups depending on prior surgical experience: a novice group (<10 procedures), an intermediate group (10-50 procedures) and an expert group (>50 procedures). All subjects performed four guidewire insertions on a TraumaVision® simulator (Swemac Innovation AB, Linköping, Sweden) in a set order. Six outcome measures were recorded; total score, time, fluoroscopy exposure, wire depth, zone of placement and wall violations. Results: There were statistically significant differences between the groups for time taken (p<0.001) and fluoroscopy exposure (p<0.001). The novice group performed the worst, and the expert group outperformed both intermediates and novices in both categories. Other outcome results were good and less variable. There was an observed learning effect in the novice and intermediate groups between each of the attempts for both time taken and fluoroscopy exposure. Conclusions: The study contributes constructive evidence to support the validity of the TraumaVision® simulator as a training tool for pedicle screw guidewire insertion. The simulator is less suitable as an assessment tool. The learning effect was evident in the less experienced groups, suggesting that VR may offer a greater benefit in the early stages of training. Further work is required to assess transferability to the clinical setting.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Higher Patient Complexities are Associated with Increased Length of Stay, Complications, and Readmissions After Total Hip Arthroplasty
Sai M. Guntaka, BA, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, John M. Tarazi, MD, Zhongming Chen, MD, Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Rushabh Vakharia, MD, Maimonides Medical Center, Brooklyn, New York, Martin W. Roche, MD, Hospital for Special Surgery Florida, West Palm Beach, Florida
1412
Introduction: There is an increased incidence of complex patients undergoing total hip arthroplasty (THA), which demands a rigorous preoperative, intraoperative, and postoperative assessment. It is important how increases in patient complexity impact a variety of patient outcomes. Therefore, the purpose of our study is to determine if a higher Elixhauser Comorbidity Index (ECI), a measure of patient complexity, is correlated with: 1) longer hospital length of stay; 2) increased 90-day medical complications; 3) higher 90-day readmissions; and 4) greater two-year implant-related complications following primary THA.
Materials and Methods: Patients undergoing primary THA from January 1, 2004 to December 31, 2015 were queried from the Medicare Standard Analytical Files using the International Classification of Disease, ninth revision (ICD-9) procedure code 81.51. The queried patients (387,831) were filtered by ECI scores of 1 to 5. Patients who have ECI scores of 2 to 5 represented the study cohorts and were matched according to age and sex to patients who have the lowest ECI score (ECI of 1). All cohorts were longitudinally followed to assess and compare hospital length of stay, 90-day medical complications, 90-day readmissions, and two-year implant-related complications. We compared odds-ratios (OR), 95% confidence intervals (95% CI), and p-values using logistic regression analyses and Welch’s t-tests.
Results: Patients who have ECI scores greater than 1 had higher hospital length of stay (p<0.001), 90-day medical complications (p<0.001), 90-day readmissions (p<0.001), and two-year implant-related complications (p<0.001). Patients who have an ECI score of 2 (1.26, 95% CI: 1.20–1.32), ECI of 3 (1.61, 95% CI: 1.53–1.69), ECI of 4 (2.05, 95% CI: 1.95–2.14), and ECI of 5 (2.32, 95% CI: 2.21–2.43) had an increasing trend for readmissions, with higher ECI scores correlating with greater odds of readmission following primary THA. Two-year implant-related complications also showed a similar increasing trend with greater patient complexity. Patients who had an ECI score of 5 (2.54, 95% CI: 2.39–2.69) had more implant-related complications compared to patients who had an ECI score of 2 (1.39, 95% CI:1.31–1.48).
Conclusion: The results of this study illustrate that a higher Elixhauser-Comorbidity Index is an independent risk factor for longer hospital length of stay, higher 90-day medical complications, greater 90-day readmissions, and increased two-year implant-related complications following primary THA. This study is important as it further defines and heightens awareness of adverse events for complex patients undergoing this procedure. Future studies can examine if these events can potentially be mitigated through reductions in ECI scores prior to surgery and increased incentives for the healthcare team.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Total Shoulder Arthroplasty Using OVO®/OVO® Motion with Inlay Glenoid Shoulder Arthroplasty System
Sercan Yalcin, MD, Michael Scarcella, MD, Anthony Miniaci, MD, Professor of Surgery, Cleveland Clinic Sports Health Center, Garfield Heights, Ohio
1406
The incidence of patients undergoing total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis has been steadily increasing in the United States. TSA with humeral head resurfacing with an inlay glenoid using OVO®/OVO® Motion (Arthrosurface, Inc., Franklin, Massachusetts) is an anatomic implant solution to shoulder arthritis. Anatomic resurfacing has demonstrated promising clinical- and patient-reported outcomes in the literature in both active and low-demand patients. Furthermore, patients are capable of returning to high-demand activities, such as weightlifting, which are restricted with conventional total shoulder replacement designs. Resurfacing designs offer a simple solution to a complex problem.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Recurrent Instability after Arthroscopic Glenoid Labral Repair with a Minimum of Three Points of Fixation: Do the Number of Anchors or Fixation Points Correlate to Outcomes?
Sean Mc Millan, DO, Virtual Health Systems, Burlington, New Jersey, Brian Fliegel, DO, Michael Stark, DO, Manuel Pontes, PhD, Michael Markowitz, DO, Rowan School of Osteopathic Medicine, Stratford, New Jersey, Elizabeth Ford, DO, Inspira Health Network, Vineland, New Jersey
1411
Introduction: The goal of this study was to evaluate the recurrence rate of instability following arthroscopic Bankart repairs in regard to the number and types of fixation utilized. A Bankart lesion is a tear in the anteroinferior capsulolabral complex within the shoulder, occurring in association with an anterior shoulder dislocation. These injuries can result in glenoid bone loss, decreased range of motion, and recurrent shoulder instability. Successful repair of these lesions has been reported in the literature with repair constructs that have three points of fixation. However, the definition of “one point of fixation” is yet to be fully elucidated.
Materials and Methods: A consecutive series of arthroscopically repaired Bankart lesions were evaluated pertaining to the points of fixation required to achieve shoulder stability. This included the number, position, and types of anchors used. Patients consented to complete a series of surveys at a minimum of two years postoperatively. The primary outcome was to determine recurrent instability via the UCLA Shoulder Score, the ROWE Shoulder Instability Score, and the Oxford Shoulder Score. A secondary outcome included pain on a Visual Analog Scale (VAS).
Results: There were 116 patients reviewed, 46 patients achieved three points of fixation in their surgical repair via two anchors and 70 patients achieved a similar fixation with three or more anchors. There was no significant difference in the mean age, gender, or body mass index (BMI). Patients receiving two anchors demonstrated recurrent instability 8.7% of the time (4 of 46 patients). Patients who received three or more anchors demonstrated recurrent instability 8.6% of the time (6 of 70 patients). Overall, there was no statistical significance between the number/types of anchors used. Between the two cohorts, there was no statistically significant difference found between VAS, ROWE, UCLA, and Oxford Scores. There was a significant difference in pain reported on the VAS scale with an average VAS score of 0.43 versus 2.5 in those without and with recurrent instability respectively.
Conclusion: Contention still exists surrounding the exact definition of “a point of fixation” in arthroscopic Bankart repairs. Three-point constructs can be created through a variety of combinations including anchors and sutures, ultimately achieving the goal of a stable shoulder.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Adoption of Robotic Arm-Assisted Total Hip Arthroplasty Results in Reliable Clinical and Radiographic Outcomes at Minimum Two-Year Follow Up
Matthew Hepinstall, MD, NYU Langone Health, New York, New York, Harrison Zucker, BS, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, Chelsea Matzko, BA, Orthopaedic Institute at Lenox Hill, New York, New York, Morteza Meftah, MD, NYU Langone Orthopedic Center, New York, New York, Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
1420
Introduction: Longevity and success of total hip arthroplasty (THA) is largely dependent on component positioning. While use of robotic platforms can improve this positioning, published evidence on its clinical benefits is limited. Therefore, the aim of this study was to assess the clinical outcomes of THA with robotic surgical assistance.
Materials and Methods: We conducted an analysis of robotic arm-assisted primary THAs performed by a single surgeon utilizing a posterior approach. A total of 99 patients (107 cases) who had a minimum two-year follow up were identified. Their mean age was 61 years (range, 33 to 84 years), and their mean body mass index was 30.5 kg/m2 (range, 18.5 to 49.1 kg/m2). There were 56% female patients and primary osteoarthritis was the principal hip diagnosis in 88.8%. Operative times, lengths of hospital stay, and discharge dispositions were recorded, along with any complications. Modified Harris Hip Scores (HHS) were calculated to quantify clinical outcomes.
Results: Mean postoperative increases in HHS at 2- to 5.7-year follow up was 33 points (range, 6 to 77 points). There were no complications attributable to the use of robotic assistance. Surgical-site complications were rare; one case underwent a revision for prosthetic joint infection (0.93%) but there were no dislocations, periprosthetic fractures, or cases of mechanical implant loosening. There was no evidence of progressive radiolucencies or radiographic failure.
Discussion: Robotic arm-assisted THA resulted in low complication rates at minimum two-year follow up, with clinical outcomes comparable to those reported with manual surgery.1–4 The haptically-guided acetabular bone preparation enabled reliable cementless acetabular fixation and there were no adverse events related to the use of the robot. Dislocations were avoided in this case series. Randomized controlled clinical trials are needed to compare manual to robotic surgery and to investigate whether the precision found with this functional planning will reliably reduce the incidence of dislocations.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Outcomes of Rotating-hinge Total Knee Arthroplasty Following Complex Primary and Revision Total Knee Arthroplasty
Daniel Pfeufer, MD, Jeremy Gililland, MD, Priscila Monteiro, MSc, Marissa Stagg, BSc, Mike B. Anderson, MSc, Christopher L. Peters, MD, Christopher E. Pelt, MD, Department of Orthopedics, University of Utah, Salt Lake City, UT, USA
1407
In complex primary and revision total knee arthroplasty (TKA), rotating-hinge TKA (RH-TKA) prostheses play an important role. Compared to early fixed-hinge knee designs, new implants that include rotating platforms and improved hinge constructs may offer improvements in both survival and clinical outcomes. We sought to evaluate early survival following complex primary and revision TKA with a rotating-hinge knee prosthesis.
We retrospectively reviewed a consecutive series of patients (n=47, 48 knees) who underwent revision TKA using an RH-TKA system. The mean age was 73 years (range, 37 – 86). The mean body mass index was 29 (range, 16.3 – 45.9) and the median ASA score was 3 (IQR, 2 – 3). As mortality was high, we performed a Kaplan-Meier analysis to evaluate survival, with death as failure. The median follow-up was 2.5 years (range, 0.07 – 9.8).
Revision-free survival was 97% at a median 2.5 years of follow-up. Overall mortality was 46% (17/37) and survival free from death was 69% (49% - 82%) at a median of 2.5 years. Most reoperations were due to infection (5/12), following by wound-related complications (2/12) and hematomas (2/12).
A high postoperative complication rate and mortality are evident in TKA using a hinged knee prosthesis in complex revision TKA. If the indication and surgical technique are matched to the complexity of the case, this type of implant offers a feasible salvage procedure.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Closed Incisional Negative Pressure Wound Therapy (ciNPWT) in Oncological Orthopedic Surgery: Preliminary Report
Livia Gabriele, MD, Gabriele Gariffo, MD, Edoardo Ipponi, MD, Rodolfo Capanna, MD, PhD, Ordinary Professor, Lorenzo Andreani, MD, PhD, University of Pisa, Pisa, Italy, Stefano Grossi, MD, Cecina Hospital, Cecina, Italy
1429
This report presents the authors’ experience with surgical wound-healing using a negative-pressure wound therapy (NPWT) device in a population of oncological orthopedic patients.
Two groups of 26 oncological patients each underwent surgical excision. After surgery, the control group received standard dressings and the closed incisional NPWT (ciNPWT) group was treated with a ciNPWT system on the sutured wound area for 14 days.
As a primary endpoint, the percentage of post-surgery wound-site complications using ciNPWT devices was compared to that with standard patch dressings. Overall, 30.7% of the control group and 7.7% of the ciNPWT group manifested wound-site complications within 2 weeks after surgery. As a secondary endpoint, final wound healing was compared between the groups: delayed wound healing was observed in 4 (15.4%) patients in the control group and in none (0%) of those in the ciNPWT group. Finally, the length of stay (LOS) was 6.3 days in the control group and 5.1 days in the ciNPWT group.
These results suggest that the ciNPWT device could be beneficial in minimizing the incidence of short-term surgical-site complications and decreasing length of stay in high-risk patients, such as those undergoing oncological orthopedic surgery.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Clinical Outcomes of Conical Hip Prosthesis Used In Primary Total Hip Arthroplasty
Akhil Katakam Melnic, MBA, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, Christopher M. Melnic, MD, Massachusetts General Hospital, Harvard Medical School, George Hanson, MD, Hennepin Healthcare System, Franklin, Missouri, Hany S. Bedair, MD, Associate Professor of Orthopaedic Surgery, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts
1436
Introduction: Congenital dysplasia of the hip, presence of intramedullary bony pedestals, and related pathologies present unique challenges to the orthopaedic surgeon when considering total hip arthroplasty (THA). In these circumstances, a conical prosthesis has proven to be effective. The purpose of this study is to report the short-term radiological and clinical outcomes of the Wagner Cone Prosthesis® (Zimmer Biomet, Warsaw, Indiana) utilized for a range of etiologies at a major North American healthcare system.
Materials and Methods: A retrospective study was performed at a single healthcare system between 2007 and 2018. Demographic variables, including age, sex, and laterality, as well as surgical variables, including femoral head size, neck-shaft angle, stem diameter, surgical approach, and indication for THA, were collected for each hip. Radiographs were also examined for subsidence, limb length discrepancy (LLD), and Crowe classification if the hip was dysplastic.
Results: Thirty-one THAs were performed using a Wagner Cone Prosthesis®. No intraoperative or postoperative implant-related complications were reported. Fourteen hips were dysplastic, and of these, 10 were classified as Crowe I, one as Crowe II, two as Crowe III, and one as Crowe IV. No implant was observed to have subsidence greater than 1cm. The average LLD following arthroplasty was 1.38mm ± 9.4mm shorter than the contralateral side.
Conclusion: The Wagner Cone Prosthesis® serves as a useful implant for THA. In our sample, it had excellent survivorship, impressive postoperative radiographic measurements obtained from most recent follow up, minimal mean subsidence, and minimal complication rates.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Mid-Term Clinical Outcomes and Survivorship of a Second-Generation Modular Revision Knee System
Mark T. Kolich, DO, Joanne B. Adams, BFA, CMI, Michael J. Morris, MD, Joint Implant Surgeons, Inc., New Albany, Ohio, Keith R. Berend, MD, Jason M. Hurst, MD, Adolph V. Lombardi Jr., MD, FACS, Clinical Assistant Professor, David A. Crawford, MD, Joint Implant Surgeons, Inc., New Albany, Ohio
1438
Introduction: Revision knee systems have adapted to the challenges of revision knee arthroplasty with offset stems, augments, cones, and various levels of constraint. The purpose of this study is to review the mid-term outcomes of a second-generation modular knee revision system.
Materials and Methods: A retrospective review was conducted from 2011 through 2014 on all patients who underwent knee arthroplasty with the Vanguard® 360 revision knee system (Zimmer Biomet, Warsaw, Indiana). Patients were included in the study if they were eligible for five-year minimum follow up and had signed a general research consent. The initial query revealed 253 patients (267 knees) that met inclusion criteria. Complications assessed were manipulation under anesthesia (MUA) and revision of any component. Statistical analysis using paired t-test was performed to evaluate changes in clinical outcomes and Kaplan-Meier survival analysis.
Results: Mean follow up was 6.6 years. The Vanguard® 360 knee system was used in four (1.5%) primary total knee arthroplasties (TKAs), 66 (24.7%) second-stage reimplantation TKAs after infection, and 197 (73.8%) aseptic revisions. There were significant improvements in knee range of motion and Knee Society Scores (all p<0.05). Manipulations under anesthesia were performed in 17 knees (6.4%). A total of 41 knees (15.4%) failed for any cause and required re-revision surgery. Of these, 11 (4.1%) failed due to aseptic loosening. Kaplan-Meier analysis revealed overall survival to endpoint of aseptic loosening to be 96.4% (95% CI: ±1.2%) at five years and 95.2% (95% CI: ±1.4%) at 9.5 years. When comparing survivorship in patients who underwent initial revision for aseptic indications compared with those whose underwent revision for second-stage reimplantation after infection, Kaplan-Meier survival to endpoint of revision for any cause at 9.5 years was higher for patients with aseptic than septic indication for TKA (87.0% [95% CI: ±2.4%] vs. 75.3% [95% CI: ±5.4%], p=0.0156).
Conclusion: The findings of this study demonstrate greater than 95% aseptic survivorship with the use of the Vanguard® revision knee system at mid-term follow up.
Order Digital ePrint:
PDF Format - $115.00
100 ePrints - $495.00
1 Year Subscription
including this article:
Online PDF - $399.00
Postoperative Outcome of Patients Who Underwent Total Joint Replacement During the Tanezumab Phase 3 Osteoarthritis Development Program: A 24-Week Observational Study
Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, John A. Carrino, MD, MPH, Professor of Radiology, Hospital for Special Surgery, New York, New York, Mary Anne Nemeth, MA, Aimee Burr, MS, Takaharu Yamabe, PhD, Mark T. Brown, MD, Christine R. West, PhD, Kenneth M. Verburg, PhD, Pfizer Inc, Groton, Connecticut, Lars Viktrup, MD, PhD, Eli Lilly and Company, Indianapolis, Indiana
1439
Introduction: This prospective cohort study (ClinicalTrials.gov identifier: NCT02674386) evaluated the postoperative outcomes of patients who had undergone total joint replacement (TJR) while participating in one of three tanezumab (a nerve growth factor inhibitor) randomized phase 3 osteoarthritis (OA) studies.
Materials and Methods: Eligible patients were those who underwent TJR (knee, hip, or shoulder) at any time during any of three tanezumab randomized phase 3 OA studies. Consenting patients were followed for 24 weeks post-surgery. Patients undergoing sub-total arthroplasty procedures were not eligible; there were no further protocol-defined exclusion criteria. Outcomes assessed in relation to joint adjudication outcome and prior tanezumab treatment included: 1) surgeon’s assessment of procedural difficulty (uneventful, minor complications, major complications) at the time of the TJR; 2) postsurgical complications (clinically significant events attributable to the TJR, derived from adverse events) up to week 24; and 3) additional/corrective procedures (procedures or investigations related to the TJR) up to week 24.
Results: The 150 patients had received placebo (n=20), tanezumab 2.5mg (n=52), tanezumab 2.5mg titrated to 5mg (tanezumab 2.5/5mg, n=8), tanezumab 5mg (n=53), or a nonsteroidal anti-inflammatory drug (n=17) in the parent studies. The 150 patients were adjudicated to have primary osteonecrosis (n=1), rapidly progressive OA (RPOA) type 2 (n=8), RPOA type 1 (n=3), other joint outcome (n=6), normal progression of OA (NPOA) (n=130), or insufficient information to determine RPOA versus NPOA (n=2). Surgeon’s assessment of procedural difficulty was uneventful for 95.1% (116/122) of patients. Through the 24-week study, there were no postsurgical complications for 96.0% (144/150) of patients; the 6 patients who had complications were all adjudicated as NPOA (tanezumab 2.5mg, n=2; tanezumab 5mg, n=4). There were no additional/corrective procedures for 93.3% (140/150) of patients.
Conclusion: Procedural difficulty of minor complications during surgery, postsurgical complications, and additional/corrective procedures were infrequent, although more common with tanezumab 5mg, typically occurring in patients adjudicated as NPOA. Adjudication outcome (RPOA/primary osteonecrosis vs. NPOA) was not associated with postoperative outcome.
