Surgical Technology International
39th Edition.
New Online Studies
Online First -Aug 2021
ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Robotic Applications for Benign Gynecologic Procedures
Alexandria Connor, MD, Resad Pasic, MD, PhD, Professor of Obstetrics and Gynecology, Amira Quevedo, MD, FACOG,
Petra Chamseddine, MD,
University of Louisville School of Medicine,
Louisville, Kentucky
1409
Introduction: Robotic systems provide a platform for surgeons to expand their capabilities, allowing them to perform complex procedures safely and efficiently. Within the field of benign gynecology, this has become an increasingly popular option since receiving Food and Drug Administration (FDA) approval in 2005. However, the appropriate indications for robotic versus laparoscopic surgery continue to be debated.
Materials and Methods: Literature was reviewed to provide a comprehensive, evidence-based evaluation of the advantages and pitfalls of robotic surgery, the applications of robotic surgery for benign gynecologic procedures in comparison to conventional laparoscopy, and the role of robotic surgery as an educational tool.
Results: Robotic surgery has favorable outcomes for surgeons in the areas of ergonomics, dexterity, and fatigue. Cost comparisons are widely varied and elaborate. Most patient outcomes are comparable between robotic and laparoscopic hysterectomies and endometriosis resections. In patients with a body mass index >30mg/m2 and uteri >750mg, hysterectomy outcomes are improved when surgery is done robotically. The use of the robotic system may be beneficial for patients undergoing myomectomy. Robotic surgery confers advantages for trainees and novice surgeons. There is no consensus on a standardized curriculum for robotic training or credentialing process for experienced surgeons.
Conclusion: Robotic surgery has distinct features that make it a valuable tool for gynecologic surgeons. There are no clear indications regarding when a robotic route should be chosen but could be considered when above average complexity is anticipated and when training new surgeons.
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Twenty Years’ Experience with Endovenous Laser Ablation for Varicose Veins: A Critical Appraisal of the Original Procedure
Bernardus Carolus Vincentius Maria Disselhoff, MD, PhD, Mosaderma Clinics, Hoensbroek, The Netherlands, Daan Joan der Kinderen, MD, PhD, Sanalink, The Netherlands
1453
Objective: A critical appraisal of the original procedure of endovenous laser ablation (EVLA) for varicose veins.
Method: Evaluation of all practical aspects of the procedure.
Results: EVLA procedures are performed in a strictly ambulatory setting with tumescent local anesthesia (TLA). Technical improvements have resulted in the need for fewer incisions and re-punctures, less ecchymosis, and fewer technical failures. Administration of an appropriate amount of TLA via an infusion pump has reduced the risk of nerve injury, administration time, and pain during the procedure. Use of a 1470-nm diode laser and a radial fiber have significantly improved patient satisfaction and reduced the occurrence of complications such as pain, tightness, ecchymosis, and the need for additional procedures. Lastly, there are only a few indications left for high ligation and stripping.
Conclusion: Over the past 20 years, EVLA has evolved into an effective, cost-efficient, and safe procedure that provides high patient satisfaction.
Effect of Topical Oxygen Therapy on Chronic Wounds
Crystal V. James, MD, So Youn Park, MD, John C. Lantis II, MD, Professor, Mount Sinai West/Morningside, New York, NY, Denise Alabi, BA, Mount Sinai Health System, New York, NY
1456
Over the past three decades, there has been a growing interest in the use of oxygen therapy to promote wound healing. Although the most commonly recognized oxygen therapy for the treatment of chronic wounds is hyperbaric oxygen therapy, topical oxygen therapy has a greater level of evidence supporting its use in chronic wound care. Still, it is imperative that these two treatment modalities be recognized not merely as competitors, but as distinct therapeutic entities. Through personal experience and a thorough literature review, we investigated the use of topical oxygen therapy in the management of chronic wounds. The benefits of using topical oxygen therapy have been demonstrated in patients with diabetic foot ulcers, ischemic ulcers, post-revascularization ulcers, and pressure ulcers. There are several topical oxygen devices currently on the market that are versatile, relatively low-risk, and generally well-tolerated by patients. While these devices have been used in the treatment of chronic wounds at different locations and of different etiologies, other uses of these devices are still being investigated. Topical oxygen therapy is yet another tool in our arsenal to be used in treating difficult to heal chronic wounds and could potentially be used more readily.
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Laparoscopic Inguinal Hernia Repair—TAPP versus TEP: Results of 301 Consecutive Patients
Beslen Goksoy, MD, Ibrahim F Azamat, MD, Ibrahim H Ozata, MD, Kazim Duman, MD, Department of General Surgery, Sehit Prof. Dr. Ilhan Varank, University of Health Sciences, Istanbul, Turkey, Gokhan Yilmaz, MD, Istanbul Medipol University, Istanbul, Turkey
1427
Introduction: Transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) hernia repair are the two most commonly used techniques in laparoscopic inguinal hernia repair, and the results of comparative studies are conflicting. The objective of this study is to compare the two methods in unilateral inguinal hernia repair.
Materials and Methods: The data of consecutive patients who underwent TEP and TAPP due to unilateral inguinal hernia between December 7, 2017, and March 15, 2020, were analyzed retrospectively. The primary outcome was to compare the clinical outcomes of the two techniques in terms of complications, conversion, pain, and operative time. The secondary outcome was recurrence rates.
Results: A total of 301 (TEP n=234, TAPP n=67) patients were included in the study. The mean age was 43 years, and the follow-up period was two years. The groups were similar in terms of demographic characteristics and hernia type. The mean operative time was longer in the TAPP group than in the TEP group (67 min and 58 min, p=0.007). The recurrence rate was 4.3% in the TEP group and 5.9% in the TAPP group (p>0.05). The conversion rate was 6% in both groups. In total, 19 (6.3%) patients had intraoperative complications (TEP n=16, TAPP n=3), and 23 (7.6%) patients had postoperative complications (TEP n=16, TAPP n=7). Both intraoperative and postoperative complication rates were similar between the groups (p=0.31 and p=0.051, respectively). The early postoperative pain was less in the TEP group (p=0.004).
Conclusion: Less early postoperative pain and shorter operative time were detected in patients who underwent TEP.
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Dermal Fibroblasts from Chronic Wounds Exhibit Paradoxically Enhanced Proliferative and Migratory Activities that May be Related to the Non-Canonical Wnt Signaling Pathway
Marta Otero Vinas, PhD, Professor in Bioscience, Xiaofeng Lin, PhD, Assistant Professor, Vincent Falanga, MD, Professor of Dermatology and Biochemistry, Polly Carson, Research Assistant Professor, Boston University School of Medicine, Boston, MA, Susan MacLauchlan, PhD, Boston University School of Medicine, Boston, MA
1451
It is generally thought that dermal fibroblasts from chronic wounds are in a state of senescence, which contributes to the failure to heal. This assumption, based on limited experimental evidence, has led to the widespread use of therapeutic approaches focused on delivering new fibroblasts and/or increasing resident fibroblast activity to promote healing. In this study, we decided to re-visit the evidence for the relative inactivity of resident chronic wound fibroblasts. We therefore evaluated the proliferative and migratory activities of matching, patient-derived dermal fibroblasts from a chronic wound (wound dermal fibroblasts, or WDF), ipsilateral thigh newly created acute wound dermal fibroblasts (ADF, Day-3 after wounding the normal thigh skin), and ipsilateral thigh normal dermal skin fibroblasts (NDF). This approach was used in each of 10 consecutive non-selected individual patients with a venous leg ulcer, and allowed us to determine whether WDF are intrinsically less active than NDF and AWD. Cell migration and proliferation were quantified by a live-cell analysis system and MTT assay, respectively, in low (0.5%) or high (10%) levels of fetal bovine serum (FBS). In addition, the ability of patient-derived fibroblasts to modulate wound re-epithelialization in vivo was analyzed by transplantation in a mouse tail full-thickness wound model. Wnt5a mRNA, its ROR1 co-receptors, and ROR2 mRNA levels were determined by qRT-PCR. We report that WDF had increased -SMA and increased levels of Wnt5a. Moreover, using live-cell imaging in a scratch assay monolayer model, WDF showed baseline migratory activity similar to those of NDF and ADF, and such activity was not stimulated by FBS. WDF showed the same capacity to increase wound re-epithelialization as NDF and ADF. Together, these results suggest that WDF are not actually less "active" than NDF and ADF. This enhanced activity of chronic wound fibroblasts may lead to high energy requirements that contribute to a failure to heal. The findings may represent a new paradigm for wound chronicity, impaired healing, and high recurrence rates.
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The Utility of Telehealth in the Recovery From the COVID-19 Pandemic
Zhongming Chen, MD, John M. Tarazi, MD, Hytham S. Salem, MD, Giles R. Scuderi, MD, Michael A. Mont, MD, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
1445
Telehealth has recently been used more often in an attempt to protect practitioners and patients during the 2019 coronavirus infectious disease (COVID-19) crisis. Despite telehealth’s existence, there was no prior need to fully realize its potential. Recently, technological innovations in orthopaedic surgery have assisted in making this modality more useful. However, it is important to continually educate the medical community regarding these technologies and their interplay to improve patient care. Therefore, our purpose is to provide information on telehealth by assessing: (1) steps the hospital/system are taking to reduce COVID-19 exposure for teams and patients; (2) new technologies allowing for the optimization of patient safety; and (3) use of telehealth for postoperative follow up. We will demonstrate that telehealth and its associated strategies can be used effectively to decrease COVID-19 exposure risks for both medical staff and patients during these rapidly changing and uncertain times.
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Total Artificial Heart Update
Jack Copeland, MD, Emeritus Professor of Cardiothoracic Surgery, Banner University Hospital, Tucson, AZ, Steve Langford, BSEE, Joseph Giampietro, RN, BSN, John Arancio, BA, SynCardia Systems, Tucson, AZ, Francisco Arabia, MD, MBA, Banner University Medical Center, Phoenix, AZ
1449
The SynCardia Total Artificial Heart (TAH, SynCardia Systems, Tucson, AZ) is the only biventricular cardiac replacement approved for bridge to transplantation by the U.S. Food and Drug Administration (FDA) and which carries the European Union CE mark. It has been implanted in about 2000 patients. In experienced centers, 60 to 80 % of implanted patients have been transplanted and over 80 % of those transplanted have lived for over 1 year.
The SynCardia TAH has supported potential cardiac recipients with irreversible biventricular failure for up to 6 years, providing physiologic pulsatile flows of 6 to 8 L/min at filling pressures of less than 10 mmHg allowing for optimal perfusion and recovery of organs such as the kidneys and liver. It is a tested device that provides a method for recovering potential transplant candidates who rapidly decompensate from biventricular failure or who have chronic cardiac failure from a variety of etiologies.
This article covers the history, mechanical function and monitoring, implantation, patient selection and management, and outpatient use. It also reviews outcome data from the original FDA study as well as contemporary data from experienced centers.
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Irreversible Electroporation as an Alternative to Wound Debridement Surgery
Bodhisatwa Das, PhD , Assistant Professor, Indian Institute of Technology Ropar, Punjab, India, Francois Berthiaume, PhD, Professor of Biomedical Engineering, Rutgers University, Piscataway, New Jersey
1452
Debridement is a standard part of wound care that is used on both acute and chronic wounds. Current methods of wound debridement include: autolytic based on the natural immune response, surgical, enzymatic based on application of exogenous proteases, mechanical using water jets and ultrasound, and biological using live organisms such as maggots. The choice of individual methods involves a trade-off between speed of treatment, selectivity, and pain. Irreversible electroporation via the application of pulsed electric fields has been used as a novel approach for deep tissue ablation, sometimes in conjunction with chemotherapy, as in the case of tumors, and also in cases where high precision is needed in otherwise very fragile tissues, such as for treating diabetic neuropathy and in epicardial atrial ablation. This method could be readily extended to wound care as it is both rapid and relatively painless, and it is also effective at decreasing bacterial load and clearing biofilms. Furthermore, the process primarily targets cells leaving the extracellular matrix relatively intact, thus providing a suitable natural scaffold for host cellular invasion and regrowth. A unique aspect of the use of pulsed electric fields is that around the region where ablation is perfomed, electric fields of lower energy are dissipated into the healthy tissue. There is a range of electric fields that are known to stimulate cellular functions, in particular migration and proliferation, and that may contribute to the healing process after electroporation. While irreversible electroporation is a potentially useful alternative to other debridement methods, future clinical application awaits technological advances in electrode design that will enable precise delivery of the therapy in wounds of various sizes and depths.
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Development of Endoscopic Surgery Navigated by Artificial Intelligence
Masafumi Inomata, MD, PhD, Professor, Atsuro Fujinaga, MD, Hiroaki Nakanuma, MD, Yuichi Endo, MD, PhD, Assistant Professor, Tsuyoshi Etoh, MD, PhD, Associate Professor, Oita University Faculty of Medicine, Oita, Japan, Tatsushi Tokuyasu, PhD, Professor, Fukuoka Institute of Technology Faculty of Information Engineering, Fukuoka, Japan, Seigo Kitano, MD, PhD, President, Oita University, Oita, Japan
1432
Endoscopic surgery, which was first introduced in the late 1980s, has rapidly become widespread. However, despite its popularity, the occurrence of intraoperative organ damage has not necessarily decreased. To avoid intraoperative bile duct injury in laparoscopic cholecystectomy, which is one of the most popular procedures in endoscopic surgery, we are developing a laparoscopic surgical system that uses Artificial Intelligence (AI) to identify four anatomical landmarks (cystic duct of the gallbladder, common bile duct, lower surface of hepatic S4, and Rouviere’s sulcus, related to “Calot’s triangle") in real time during surgery. The development process consists of 5 steps: 1) identification of anatomical landmarks, 2) collection and creation of teaching data, 3) annotation and deep learning, 4) validation of development model, and 5) actual clinical performance evaluation. At present, anatomical landmarks can be identified with high accuracy in an actual clinical performance test in laparoscopic cholecystectomy, whereas issues for practical clinical use, such as a need to recognize the scene of surgical steps and surgical difficulties related to inflammation of the gallbladder, have also been clarified. The development of an AI-navigation system for endoscopic surgery, which could identify anatomical landmarks in real time during surgery, could be expected to support surgeons' decisions, reduce surgical complications, and contribute to improving the quality of surgical treatments.
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Total Knee Arthroplasty in the Valgus Knee: Can New Operative Technologies Affect Surgical Technique and Outcomes?
Robert C. Marchand, MD, Kelly B. Taylor, BSN, Ortho Rhode Island, Wakefield, Rhode Island, Laura Scholl, MS, Manoshi Bhowmik-Stoker, PhD, Stryker Orthopaedics, Mahwah, New Jersey, Kevin B. Marchand, MS, Zhongming Chen, MD, Michael A. Mont, MD, Lenox Hill Hospital, New York, New York
1462
Introduction: Valgus knee deformities can sometimes be challenging to address during total knee arthroplasties (TKAs). While appropriate surgical technique is often debated, the role of new operative technologies in addressing these complex cases has not been clearly established. The purpose of this study was to analyze the usefulness of computed tomography scan (CT)-based three-dimensional (3D) modeling operative technology in assisting with TKA planning, execution of bone cuts, and alignment. Specifically, we evaluated valgus TKAs performed using this CT-based technology for: (1) intraoperative implant plan, number of releases, and surgeon prediction of component size; (2) survivorship and clinical outcomes at a minimum follow up of one year; and (3) radiographic outcomes.
Materials and Methods: A total of 152 patients who had valgus deformities receiving a CT-based TKA performed by a single surgeon were analyzed. Cases were performed using an enhanced preoperative planning and real-time intraoperative feedback and cutting tool. The surgeon predicted and recorded implant sizes preoperatively and all patients received implants with initial and final implant alignment, flexion/extension gaps, and full or partial soft tissue releases recorded. A modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR.) scores were collected preoperatively and at approximately six months and one year postoperatively. Preoperative coronal alignment ranged from 1 to 13° valgus. Follow-up radiographs were also evaluated for alignments, loosenings, and/or progressive radiolucencies.
Results: A total of 96% of cases were corrected to within 3° of mechanical neutral. For outlier cases, initial deformities ranged from valgus 5 to 13°, with final alignment ranging from 4 to 8° valgus (mean 4° correction). Patients had mean femoral internal rotation of 2° and mean femoral flexion of 4°. The surgeon was within one size on the femur and tibia 94 and 100% of the time, respectively. Only one patient required a lateral soft tissue release and one patient had osteophytes removed, which required a medial soft tissue release. Five patients required manipulations under anesthesia. Aside from these, there were no postoperative medical and/or surgical complications and there was 100% survivorship at final follow up. WOMAC and KOOS, JR. scores improved significantly from a mean of 21 ± 9 and 48 ± 10 points preoperatively to 4 ± 6 (p<0.05) and 82 ± 15 (p<0.05) at final follow up, respectively. None of the cases exhibited progressive radiolucencies by final follow up.
Discussion: A limitation of this study was not evaluating dynamic kinematics in these patients to determine if rotation had any effects on kinematics. Future studies will evaluate this concern. Nevertheless, the technology successfully assisted with planning, executing bone cuts, and achieving alignment in TKAs complicated by the deformity. This may allow surgeons to predictably avoid soft tissue releases and accurately know component sizes preoperatively, while consistently achieving desired postoperative alignment.
Conclusions: This study demonstrated the utility of CT-based 3D modeling techniques for challenging valgus deformity cases. Use of 3D modeling allowed the TKA components to be positioned according to the patient’s anatomy in the coronal, transverse, and sagittal planes. When making these intraoperative implant adjustments, the surgeon may choose to place components outside the preoperative planning guidelines based on the clinical needs of the patient.
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Robotic-Assisted Total Hip Arthroplasty in Patients Who Have Developmental Hip Dysplasia
Matthew Hepinstall, MD, Associate Professor, Nishanth Muthusamy, BA, NYU Langone Health, New York, New York, Frank Mota, MD, Brandon Naylor, DO, Hytham S. Salem MD, Michael A. Mont, MD, Lenox Hill Hospital, New York, New York, Gloria Coden, BA, Zucker School of Medicine at Hofstra/Northwell, New York, New York
1454
Introduction: Total hip arthroplasty (THA) in the setting of developmental dysplasia of the hip (DDH) presents more inherent complexities than routine primary THA for osteoarthritis. These include acetabular bone deficiency, limb length discrepancy (LLD), and abnormal femoral anteversion. Three-dimensional planning and robot-assisted (RA) bone preparation may simplify these complex procedures and make them more reproducible. The purpose of this study was to evaluate radiographic and clinical outcomes in a cohort of patients who had DDH and underwent an RA THA.
Materials and Methods: We retrospectively analyzed 26 DDH patients who underwent RA THA by a single surgeon between 2013 and 2019. Their mean age was 54 years (range, 29 to 72 years) and mean follow up was approximately two years. Medical records were reviewed for demographics, clinical scores, Crowe classifications, and complications. There were thirteen Crowe I and seven Crowe II DDH hips, who were routinely managed with primary cementless implants. Two patients who had Crowe III and four patients who had Crowe IV DDH were also identified. All hips were reconstructed with cementless hemispherical acetabular components with or without the use of screws, but no acetabular augments or bulk allografts. Implants allowing control of femoral anteversion were selected in 23.1% of cases, including all six cases with Crowe III or IV dysplasia, and the need for these implants was uniformly identified using preoperative information about femoral version provided by the three-dimensional planning software. No patient was managed with a shortening femoral osteotomy. Postoperative radiographs were examined for LLD, center of rotation (COR), cup position (inclination and anteversion), and component osseous-integration.
Results: Mean radiographic LLD was 1.7mm (range, -9 to +14) in patients who had Crowe I DDH, and there was no clinical LLDs greater than 5mm observed. Although patients who had Crowe II and greater DDH had a mean radiographic LLD of -11.6mm (range, -26 to +2.2), again no clinical LLD greater than 5mm was observed other than one patient who had bilateral Crowe II DDH in whom 10mm of clinical lengthening was accepted at the index arthroplasty with the plan to match lengths when her contralateral THA was performed. There were no cases of dislocation or acetabular fixation failure. One patient who had a femoral deformity and an intra-osseous blade plate from a prior femoral osteotomy suffered a failure of femoral osseous-integration, resulting in revision. A 32-point increase in mean modified Harris Hip Score (mHHS) was found (p=0.002), from 48 points preoperatively to 80 points postoperatively.
Discussion: RA THA provides an excellent option for the arthroplasty surgeon to both preoperatively localize and characterize the acetabular deficiency, while providing a targeted, optimal, and secure placement of the components intraoperatively. Our results suggest favorable outcomes when compared to previous research on manual THA in DDH. Further studies, including comparative analyses, could discern possible advantages over traditional THA without robotic assistance in DDH.
Conclusion: Total hip arthroplasty (THA) in the setting of developmental dysplasia presents more inherent complexities than routine primary THA. Robotic-assisted THA may simplify these complex procedures.
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Evaluation of Indocyanine Green Fluorescence Imaging for Intraoperative Identification of Liver Malignancy
Jorge G. Zarate Rodriguez, MD, Chet W. Hammill, MD, MCR, FACS, Associate Professor, Washington University School of Medicine, St. Louis, Missouri, Jan Grendar, MD, MSc, Zeljka Jutric, MD, Assistant Professor, Portland Providence Cancer Center, Portland, Oregon, Paul D. Hansen, MD, The Oregon Clinic, Portland, Oregon, Maria A. Cassera, MD, University of Washington, Seattle, Washington, Ronald F. Wolf, MD, Professor of Surgery, UC Irvine Medical Center, Orange, California
1463
Introduction: There is early evidence that indocyanine green (ICG) fluorescence imaging has the ability to detect metastatic and primary malignancies in the liver that are too small to be identified by other methods. However, the rate of false positives and false negatives remains unknown.
Materials and Methods: This is a single institution prospective single-arm study. Patients with suspected hepatic or pancreatic malignancies were intravenously injected with ICG one to three days prior to their scheduled surgical therapy. At the beginning of the procedure, the liver was assessed with fluorescence imaging and all identified lesions were biopsied and evaluated.
Results: Twenty-three patients were enrolled from April 2015 through February 2016. Fifteen patients with confirmed malignancy had adequate fluorescence imaging evaluation of the liver; 10 with pancreatic primary malignancies and five with hepatic primaries. Fluorescence imaging was the only modality that identified nine concerning hepatic lesions, all of which were benign on pathology examination. Out of 11 malignant hepatic masses, six were visible on fluorescence imaging. Out of nine benign hepatic lesions, five were visible. No side effects or complications of the fluorescence imaging were encountered. The sensitivity for ICG fluorescence was 45.5%, the specificity 21.2%, the positive predictive value 25%, and the negative predictive value 40%.
Conclusion: Intraoperative hepatic assessment with ICG fluorescence imaging to identify malignancy in the liver is feasible and safe. However, in this study the significant number of false positives limit the utility of the technique. Our preliminary data do not support its routine use for detection of malignancies in the liver.
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Comparison of Iatrogenic Soft Tissue Trauma in Robotic-Assisted versus Manual Partial Knee Arthroplasty
Emily L. Hampp, PhD, Laura Scholl, MS, Ahmad Faizan, PhD, Joint Replacement Division, Stryker, Mahwah, New Jersey, Nipun Sodhi, MD, Long Island Jewish Medical Center, Northwell Health, New York, New York, Michael A. Mont, MD, Lenox Hill Hospital , Northwell Health, New York, New York, Geoffrey Westrich, MD, Professor, Hospital for Special Surgery, New York, New York
1465
Partial knee arthroplasty (PKA) is performed to treat end-stage osteoarthritis in a single compartment. There are minimal data characterizing soft-tissue injuries for PKA with robotic and manual techniques. This cadaver study compared the extent of soft-tissue trauma sustained through robotic-arm assisted PKA (RPKA) and manual PKA (MPKA). Five surgeons prepared 24 cadaveric knees for medial PKA, including six MPKA controls and 18 RPKA assigned into three different workflows: RPKA-LB (six knees) – RPKA with legacy burr; RPKA-NB (six knees) – RPKA with new burr design; and RPKA-NBS (six knees) – RPKA with new burr design and oscillating saw. Two surgeons estimated trauma to the patellar tendon, quadriceps tendon, anterior cruciate ligament (ACL), medial collateral ligament (MCL), medial capsule, posterior capsule, and posterior cruciate ligament (PCLs) using a five-grade system: Grade 1 – complete soft tissue preservation; Grade 2 – ≤25%; Grade 3 – 26 to 50%; Grade 4 – 51 to 75%; and Grade 5 – ≥76% trauma. A total trauma grade was assigned by summing the grades. Kruskal-Wallis statistical tests were used to assess outcomes. When compared to the MPKA group, all RPKA subgroups had lower total trauma grading (p<0.01), lower posterior capsular damage (p<0.01), and less severe ACL damage (p<0.01). The analysis demonstrated no significant difference between the three RPKA workflows. As this study was performed using cadaveric specimens, additional investigations are necessary to determine associations between robotic or manual-assisted technique, observed soft tissue damage, and postoperative clinical outcomes following PKA.
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A Pilot Study to Determine the Impact of Adipose Tissue Attachment to Polypropylene Fibers In Hernia Mesh
Bruce Ramshaw, MD, Brandie Remi Forman, BA, CQInsights PBC, Knoxville, Tennessee, Dave Grant, BS , Sheila Grant, PhD, Professor, University of Missouri, Columbia, Missouri
1470
Introduction: Prior publications have demonstrated chemical and physical alteration of hernia mesh analyzed after explantation from the body. The specific alteration documented is oxidative degradation of polypropylene mesh fibers. An animal study recently published has demonstrated that adipose tissue attachment is present instead of reparative fibrous tissue infiltration in an average of 10.9–18.9% of the intramesh healing for a variety of clinically used knitted polypropylene mesh products; 8.0% for knitted polyester meshes. This study also found that in comparison to the knitted mesh products, non-woven polypropylene mesh reduced adipose tissue attachment to 1% or less, which was a statistically significant difference.
Materials and Methods: Samples of explanted polypropylene mesh from eight patients were analyzed for the presence of adipose tissue attachment, reparative fibrous tissue infiltration, and oxidative changes. Greater adipose tissue attachment areas were compared with areas of greater reparative fibrous tissue infiltration for evidence of oxidative changes in the mesh to determine if the areas of higher adipose tissue attachment correlated with an increase in oxidative changes.
Results: Intra mesh healing of clinically explanted knitted meshes demonstrated adipose tissue content from 0.0% to 49.1% per analyzed segment. The oxidation index, a measure of the degree of oxidative degradation in that portion of the mesh, was higher in seven of the eight areas of greater adipose tissue attachment than areas of greater reparative fibrous tissue infiltration.
Conclusion: Adipose tissue attachment does occur in knitted and woven polypropylene hernia meshes. The presence of adipose tissue may contribute to an increase in oxidative changes in knitted polypropylene hernia mesh fibers.
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