Surgical Technology International
44th Edition
July 2024 - ISSN:1090-3941
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Risk Factors Portending a Total Hip Arthroplasty for Patients Who Have Osteonecrosis of the Femoral Head
Zhongming Chen, MD, Jeremy A. Dubin, BA, Sandeep S. Bains, MD, Daniel Hameed, MD, Mallory C. Moore, BS, Ronald E. Delanois, MD, Michael A. Mont, MD, James Nace, DO, Orthopaedic Attending, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Osteonecrosis of the femoral head (ONFH) poses a substantial burden to orthopaedic surgeons. However, the exact risk attributed by each specific patient factor for those who end up receiving a total hip arthroplasty (THA) are not well known. We assessed: (1) patient demographics (age and sex); (2) blood cell dyscrasias (sickle-cell disease and hypercoagulable states); and (3) substance use (oral corticosteroid use, tobacco use, and alcohol abuse).
Materials and Methods: A retrospective search examined all patients who had a primary THA (n=715,100) between January 1, 2010 and April 30, 2020 using a national, all-payer database. Risk factors studied included age, sex, sickle-cell, hypercoagulable state, oral corticosteroid use, tobacco use, and alcohol abuse.
Results: Several risk factors were found to be significantly predictive for ONFH requiring THA: age <55 years (odds ratio [OR] 1.02, 95% confidence interval [CI] of 1.01 to 1.02, p<0.001), men (OR 1.07, 95% CI of 1.04 to 1.10, p<0.001), oral corticosteroid use (OR 1.21, 95% CI of 1.17 to 1.25, p<0.001), tobacco use (OR 1.15, 95% CI of 1.11 to 1.18, p<0.001), and alcohol abuse (OR 1.05, 95% CI of 1.01 to 1.08, p=0.009).
Conclusions: Based on the results of this study, young age, men, oral corticosteroid use, tobacco use, and alcohol abuse are risk factors for patients who have ONFH and had a THA. The degree of risk from greatest to least were: oral corticosteroid use, tobacco use, men, alcohol abuse, and age <55 years old.
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A Novel Strategy to Substantially Reduce the Incidence of Periprosthetic Joint Infection Following Total Hip Arthroplasty with Antimicrobial Agents
Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Maryland, Matthew F. Myntti, MD, Next Science, Jacksonville, Florida, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Periprosthetic joint infections (PJI) are devastating complications following total hip arthroplasty (THA) and are the most common reason for revision following primary arthroplasty. Although several devices, techniques, and procedures have been developed to combat this serious complication, there is little consensus as to how to prevent the development of PJI at the time of index arthroplasty. This article reviews the concept and implementation of a novel antimicrobial agent to substantially reduce the incidence of PJI. The regular implementation of this infection prophylaxis should be successful in drastically reducing the rate of PJI following primary THA.
Meniscal Repair with ArthroZheal® an Autologous Bioactive Fibrin Scaffold. A New Technique and Treatment Option
George A. Skarpas, MD, PhD, Assistant Professor, Konstantinos Maniatis, PhD, Nikolaos Barmpounakis, PhD, University of Nicosia/MITERA General Hospital, Marousi-Athens, Greece, Georgios Kakavas, PhD, University of Thessaly, Volos, Greece
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Injuries of the meniscus often lead to changes in joint biomechanics, which affect the load distribution and contact stresses. The menisci consist of a peripheral vascular region (red zone) and an inner avascular region (white zone). The blood supply plays an important role in the healing of meniscal tears. Surgical treatment of such lesions includes meniscectomy/meniscoplasty and repair, depending on the type of injury, where “meniscoplasty” refers to the treatment modality that occurs under coblation.
The application of Autologous Bioactive Matrix (ABM) has been shown to promote healing in such lesions. In addition, a special type of PRF (ArthroZheal®, Vivostat A/S, Allerød, Denmark) has been demonstrated to have healing effects in extracellular matrix synthesis and cell proliferation, as well as regenerative and remodeling effects. This autologous product can be applied directly at the meniscal repair site.
We performed a prospective study on meniscus repair with ArthroZheal® alone (plus meniscoplasty) and ArthroZheal® together with an all-inside suturing technique using the STAR AccurFix Meniscal Repair Device system (STAR Sports Medicine, Beijing, China), depending on the type and the site of the lesion.
One hundred twenty knees (110 patients) were identified through the use of clinical examination and MRI scan. The study took place between January 2023 and August 2023. Two groups were created: GROUP A was treated only with ArthroZheal®(plus meniscoplasty) and GROUP B was treated with a combination of ArthroZheal® and an all-inside suturing technique (STAR AccurFix). Pre- and postoperative grading was performed with the International Knee Documentation Committee (IKDC) score and the Tegner Activity Level Scale (Tegner Score).
The results with both treatment methods were excellent and meniscus restoration has been documented on MRIs conducted 6 months post-op. In 15 patients, 2nd-look arthroscopy was performed through a nanoscope on an outpatient basis, and showed meniscal healing and remodeling. Tegner scores and IKDC scores in both groups showed significant improvement.
Meniscal repair should be performed at all costs to maintain meniscal integrity and prevent long-term degenerative changes. New treatment methods include orthobiologics and all-inside suturing techniques. The main idea is to apply an autologous biological scaffold which is able to carry cells into the meniscal lesion and to allow their differentiation, proliferation, and extracellular matrix synthesis to produce a meniscal-like tissue. Our results suggest that the application of autologous ABM (ArthroZheal®) for the treatment of such lesions by means of dry arthroscopy results in better MRI, pain management and functional results at 3 months post-op, and these improvements can persist for up to 6 months.
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Modular Revision System for Complex Hip Revisions: A Case Series
Daniel Hameed, MD, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Brittany Oster, MD, University of Maryland School of Medicine, Baltimore, Maryland, Bryan D. Springer, MD, OrthoCarolina, Rock Hill, South Carolina, Arthur L. Malkani, MD, University of Louisville, Louisville, Kentucky
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Revision total hip arthroplasty (THA) is a procedure with many challenges, especially when patients exhibit femoral bone defects. The causes of these defects vary, ranging from removal of prior implants to aseptic loosening. As surgeons navigate these challenges, a reliable surgical system is important. One modular fluted tapered system provides surgeons with tools to address complex hip revision cases. Introduced in 2003, this system has been utilized in over 180,000 procedures, demonstrating its reliability and effectiveness. Previously, the body stem came in sizes 155mm to 235mm. In the discussed case series, we present six distinct patient cases that highlight the advantages and efficacy of a newly introduced modification of the system; that is the use of smaller stemmed components (now 115mm). With each patient presenting unique challenges, we have demonstrated the use of this new short-stem version for multiple applications for various revision scenarios.
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Low Rate of Early Periprosthetic Fractures in Direct Anterior Total Hip Arthroplasty with a Triple-Tapered Wedge Stem
Patricia R. Melvin, MD, MBS, Todd Bertrand, MD, MBA, David A. Crawford, MD, Keith R. Berend, MD, Joint Implant Surgeons, Inc., New Albany, Ohio
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Introduction: Utilization of the direct anterior approach (DAA) for total hip arthroplasty (THA) has been steadily increasing in recent years. While the DAA may offer some benefits compared to other approaches, there are still risks involved including relatively higher rates of periprosthetic femur fractures, especially when combined with cementless femoral stem use. The purpose of this study is to evaluate the early postoperative femoral complications with a short triple-wedge tapered stem used in primary THA via a DAA.
Materials and Methods: A retrospective review was conducted of the arthroplasty registry of our institution from April 2022 to August 2023 to identify patients who underwent a primary THA via a DAA with the Short Medacta Stem (SMS) (Medacta International, Castel San Pietro, Switzerland). Patients were excluded if the stem was used for a revision surgery, they were within 90 days of surgery, or they refused research consent. Inclusion criteria was met in 262 patients (302 hips). Data was collected after reviewing the chart, and reports and radiographic measurements, including Dorr type and canal fit ratios, were obtained from preoperative and postoperative radiographs, respectively.
Results: A total of 302 total hips were included, 161 patients were male (53.3%) and 141 were female (46.7%), with an average age of 66.5 years (27–88, +/- 10.7 years). Average follow up was 0.3 years (range, 0.05–1.71 years). The majority of patients had a Dorr B femur (81.7%). The Median stem size used was an 8 (range, 2–15), and 89.4% of those had a collar. Average canal fill ratio was 0.83 (range, 0.43–0.98, +/- 0.07). Overall, there were two Vancouver B2a periprosthetic femoral shaft fractures (0.66%) that required revision surgery to a modular stem. In addition, there were two Vancouver Ag greater trochanteric fractures (0.66%) with acceptable alignment that did not require revision surgery. Demographic information about the patients with femoral complications is summarized in Table I. Average age of patients with femoral complications was 69.5 years, with an average canal fit ratio of 0.88.
Conclusion: We found that the triple-wedge implant had a low rate of early femoral complication in primary THA from an anterior approach and is safe for use in THA from a DAA. More follow up is needed to evaluate continuing implant survivorship and patient outcomes.
Can Robotic-Arm Assistance Decrease Iatrogenic Soft-Tissue Damage During Direct Anterior Total Hip Arthroplasty?
Emily L. Hampp, PhD, Melanie Caba, Meng, Laura Scholl, MS, Ahmad Faizan, PhD, Joint Replacement, Mahwah, New Jersey, Benjamin M. Frye, MD, Associate Professor, West Virginia University School of Medicine, Morgantown, West Virginia, Joseph P. Nessler, MD, St. Cloud Orthopedics, St. Cloud, Minnesota, Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Maryland, Michael A. Mont, MD, Orthopaedic Attending, Institute for Advanced Orthopedics, Baltimore, Maryland
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Introduction: Manual techniques for total hip arthroplasty (THA) have been widely utilized and proven to be clinically successful. However, the use of advanced computed tomography (CT) scan-based planning and haptically-bounded reamers in robotic-arm assisted total hip arthroplasty (RTHA) holds promise for potentially limiting surrounding soft-tissue damage. This cadaver-based study aimed to compare the extent of soft-tissue damage between a robotic-arm assisted, haptically-guided THA (RTHA) and a manual, fluoroscopic-guided THA (MTHA) direct anterior approach.
Materials and Methods: There were six fresh-frozen torso-to-toe cadaver specimens included, with two surgeons each performing three RTHA and three MTHA procedures. One hip underwent an RTHA and the other hip received an MTHA in each cadaver. Postoperatively, one additional surgeon, blinded to the procedures, assessed and graded damage to nine key anatomical structures using a 1 to 4 grading scale: (1) complete soft-tissue preservation to <5% of damage; (2) 6 to 25% of damage; (3) 26 to 75% of damage; and (4) 76 to 100% of damage. Kruskal–Wallis hypothesis tests were used to compare soft-tissue damage between RTHA and MTHA cases and adjusted for ties.
Results: Pooled analysis of the gluteus minimus, sartorius, tensor fascia lata, and vastus lateralis muscle grades demonstrated that cadaver specimens who underwent RTHA underwent less damage to these structures than following MTHA (median, IQR: 1.0, 1.0 to 2.0 vs. 3.0, 2.0 to 3.0; p=0.003). Pooled analysis of the calculated volumetric damage (mm3) for the gluteus minimus, sartorius, tensor fascia lata, and vastus lateralis muscles demonstrated that the cadaver specimens that underwent RTHA underwent less damage to these structures than those that followed MTHA (median, IQR: 23, 2 to 586 vs. 216, 58 to 3,050; p=0.037).
Conclusion: This cadaver-based study suggests that utilizing RTHA may lead to reduced soft-tissue damage compared with MTHA, likely due to enhanced preoperative planning with robotic-arm assisted software, real-time intraoperative feedback, haptically-bounded reamer usage, reduced surgical steps, as well as ease of use with reaming. These findings should be carefully considered when evaluating the utilization of robotic-arm assisted THA in practice.
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Use of a Novel Reverse Hip Replacement System to Address Dislocation and Instability
Adolph V. Lombardi, Jr., MD, Clinical Assistant Professor, Joanne B. Adams, BFA, CMI, JIS Orthopedics, New Albany, Ohio
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While total hip arthroplasty (THA) is an enormously successful treatment for patients with end-stage degenerative arthritis of the hip, and surgeons have optimized existing hip implants and techniques, dislocation and instability persist as a leading cause of failure. Given the tremendous success of reverse total shoulder arthroplasty in enhancing the stability of shoulder reconstruction by reversing the anatomic seating of the ball and socket components, one manufacturer (Hip Innovation Technology, LLC, Woodstock, Georgia) has developed a novel Reverse Hip Replacement System (Reverse HRS) to address the need for greater stability in reconstruction of the arthritic hip joint. Rather than the traditional anatomic components that replace the head of the femur with a spherical ball and the acetabulum with a socket with polyethylene liner mounted into the pelvis, the Reverse HRS features a cup with polyethylene liner attached to the femoral stem and a spherical metal head attached to a central trunnion inside of the porous-coated acetabular shell fixed into the pelvis. This design provides dramatically enhanced stability and improved range of motion. This article reviews relevant published literature, including results from a Canadian clinical trial and case reports from a multicenter American clinical trial monitored by the U.S. Food and Drug Administration. It also describes the components and surgical technique of reverse THA.
Are Metal Ion Levels Elevated After Dual Mobility Acetabular Systems: Minimum Five-Year Analyses
Daniel Hameed, MD, Jeremy Dubin, BA, Zhongming Chen, MD, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland , Nipun Sodhi, MD, Long Island Jewish Medical Center, New York, New York, Steven F. Harwin, MD, Mount Sinai Hospital, New York, New York
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Introduction: While dual mobility systems in total hip replacements have demonstrated reduced dislocation and revision occurrences, concerns persist about the potential elevation of metal ions in the bloodstream, leading to negative tissue reactions. Notably, there’s a scarcity of research spanning over five years post-surgery that examines cobalt and chromium levels after such implants. This study aimed to delve into these metal ion concentrations after a five-year period, building on previous metal-ion findings. We focused on: (1) cobalt concentrations in blood and urine; (2) chromium concentrations in blood and urine; (3) cobalt variations based on follow-up duration and specific implant metrics (e.g., offset, cup dimension, stem, and neck inclination); and (4) chromium variations based on the same parameters.
Materials and Methods: We tracked 57 individuals who received THA using modular dual mobility systems from January 1, 2011, to December 31, 2016, for an average span of six years (ranging from five to 10 years). At the final check-up, we measured cobalt and chromium levels in serum, plasma, blood, and urine. We also evaluated parameters like head composition and dimension, stem offset, cup dimension, and stem-neck inclination.
Results: Cobalt concentrations remained minimal, with average blood and urine values being 0.8+0.6mcg/L (standard <1.8mcg/L) and 1.2+1.0mcg/L (standard <2.8mcg/L), respectively. Two individuals exhibited a slight increase in blood cobalt concentration by 0.1 and 0.2mcg/L. Chromium averages in blood and urine were also minimal, with readings of 0.9+0.2mcg/L (standard <1.2mcg/L) and 1.3 + 0.5mcg/L (standard <2mcg/L), respectively. One individual had a marginally increased blood chromium concentration of 1.3mcg/L. Evaluations considering ceramic or cobalt-chrome heads, up to a decade of follow up, or varying implant metrics showed negligible variations in metal ion concentrations.
Conclusion: The findings reveal that over a minimum of five years (average = six years; span, five to 10 years), cobalt and chromium concentrations in patients’ systems remained within normal limits and were clinically insignificant, irrespective of the follow-up duration, head material, or implant specifications. This underscores the efficacy of dual mobility systems in ensuring minimal metal ion presence.
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True Confessions of Neutral Mechanical Disciple—How I Learned to Love a Patient-Specific Target
Nathalie Willems, PhD, Christina Esposito, PhD, Daniele De Massari, PhD, Stryker Corporation, Mahwah, New Jersey, Kevin B. Marchand, BS, Lenox Hill Hospital, New York, New York, Daniel Hameed, MD, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Gavin Clark, MD, University of Western Australia, Medical School, Crawley, Australia , Robert Marchand, MD, Orthopedics Rhode Island, Providence, Rhode Island, Michael Dunbar, MD, PhD, Dalhousie University, Halifax, Nova Scotia
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Introduction: Classical neutral mechanical alignment in total knee arthroplasty (TKA) has been a standard paradigm, while more recently, other alignment schemas, such as kinematic, individualized, and functional, have been explored. This study aimed to investigate the effect of three-dimensional (3D) computed tomography (CT)-based surgical robotics inputs on a classically trained surgeon’s TKA component positions and alignment targets over time.
Materials and Methods: Data from 1,394 consecutive robotically-assisted TKAs by a single surgeon from 2016 to 2020 were analyzed. Metrics collected included pre-balance planned implant component positions, final planned implant component positions after soft tissue balancing, and constitutional alignment from CT scans. Joint line obliquity was plotted against the arithmetic hip-knee angle (aHKA) using coronal plane alignment of the knee (CPAK). Three categories of alignment strategy were defined: true mechanical alignment (tMA), adjusted mechanical alignment (aMA), and no mechanical alignment (noMA).
Results: A shift to overall varus component positioning was observed over the years. Joint line obliquity according to CPAK showed a wider spread in later years, and the distribution of tibial and femoral coronal alignment angles expanded over time.
Conclusion: The study revealed a change in alignment targets and final positioning of components away from neutral biomechanical axes in a large volume of TKAs by a single, classically trained surgeon over five years of using a robotic arm-assisted TKA system with CT-based planning. The most dominant factor for this change was the use of 3D CT planning, allowing the surgeon to assess patient-specific anatomy and plan accordingly. Outcome data is needed to determine if this change in behavior and surgical technique was beneficial. In summary, using a CT scan-based robotically assisted technique led to a gradual and complete shift from tMA to predominantly a non-mechanically aligned philosophy in TKA.
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An Overview of Research for the Application of a Novel Biofilm-Preventing Surgical Irrigation System for Total Joint Arthroplasty Procedures in Order to Reduce the Risk of Periprosthetic Infection
Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Maryland, Matthew F. Myntti, PhD, Jeanne Lee, MS, Next Science, Jacksonville, Florida, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland.
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Periprosthetic joint infection (PJI) is a serious postoperative complication in joint arthroplasty procedures that carries substantial morbidity and mortality associated with it. Several strategies have been developed both in the preoperative, perioperative, and postoperative periods to both combat and prevent the development of this devastating complication. Intraoperative irrigation is an important modality used during arthroplasty procedures prior to the implantation of final components that seeks to eradicate any biofilm formation. In this updated review, we discuss the XPERIENCE™ Advanced Surgical Irrigation solution (Next Science, Jacksonville, Florida) and the various completed, ongoing, and planned basic science and clinical investigations associated with it. Although there is already an impressive body of literature supporting its widespread utilization, future basic and clinical trials will continue to be performed to comprehensively characterize the effect this antimicrobial solution has on eliminating the risk of PJI following arthroplasty procedures.
Evaluation of an Initial Robotic-Assisted Direct Anterior Approach Cohort Receiving a New Short Metaphyseal Filling Collared Femoral Implant
Joshua P. Rainey, MD, Jeremy M. Gililland, MD, University of Utah, Salt Lake City, Utah, Kevin Marchand, MS, Lenox Hill Hospital, CUNY School of Medicine, New York, New York, Kelly Taylor, RN, Orthopedics Rhode Island, Providence, Rhode Island, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Robert C. Marchand, MD, Orthopaedics Rhode Island Wakefield, Rhode Island
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Background: Shorter, metaphyseal-filling collared stems have become popular with the direct anterior approach (DAA), based on their ease of broaching and insertion through less invasive surgical exposures. To aid with the DAA, robotic-assisted technology provides three-dimensional computed tomography (CT) preoperative planning and intraoperative guidance to accurately assess stem version. With other femoral stems, this has been shown to provide more accurate implant planning and improved patient outcomes. The purpose of this study was to understand femoral stem placement predictability and patient outcomes for a newly designed metaphyseal-filling collared stem system through a DAA in combination with a robotic-assisted system during a single surgeon’s initial cases.
Materials and Methods: A single high-volume surgeon, experienced with robotic-assisted DAA total hip arthroplasty (THA), adopted the use of a metaphyseal-filling collared stem. Intraoperative data and patient outcomes up to six months postoperative were collected prospectively during the surgeon’s first 123 cases. Student’s t-tests (α=0.05) were used for statistical comparisons. Intraoperative and radiographic assessments were performed for all 123 cases.
Results: The estimated version with neck-cut view of the robotic-assisted system was 13.81 ± 3.81°. The final version measurement captured with the robotic-assisted system was 16.56 ± 6.61°. The difference between the estimated version and robotic-assisted measured version was, on average, 2.68 ± 5.7° (p<0.001). The femoral stem sat at the level of the calcar in all but five cases. There were no intraoperative or postoperative periprosthetic fractures. Patients reported significant improvements in reduced Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), Patient-Reported Outcomes Measurement Information System (PROMIS 10), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores throughout their six-month recovery process with no patients reporting a periprosthetic joint infection, fracture, or dislocation.
Conclusion: The use of a metaphyseal-filling collared stem with robotic-assisted DAA resulted in adequate stem version when assessed visually and with CT scan assessments. Version estimation values were improved upon over visual assessments when using the robotic system that maps out the proximal femur and the improvement was also demonstrated when compared to the prior literature. This may also be related to the stem’s collar providing a visual guide during stem placement posterior fill of this triple-tapered stem design. Although further follow up is needed to assess longer-term outcomes, at six months postoperatively, patients had significant improvements in patient-reported outcomes with all patients reporting minimal to no restrictions with their THA.
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Custom Triflange Acetabular Implants for Complex Hip Revisions: A Case Series
Daniel Hameed, MD, Jeremy A. Dubin, MD, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Ignacio Pasqualini, MD, Research Fellow, Viktor Krebs, MD, Orthopaedic Attending, Nicolas S. Piuzzi, MD, Orthopaedic Attending, Cleveland Clinic, Cleveland, Ohio
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Revision total hip arthroplasty (THA) presents a formidable challenge when addressing extensive acetabular defects, particularly in severe cases classified under Paprosky types 3A and 3B and American Academy of Orthopaedic Surgeons types 3 and 4. Traditional methods often fall short, prompting the potential use of custom triflange acetabular components or patient-specific acetabular implants (PSAIs). These implants are specifically designed to conform to an individual’s anatomy, aiming to enhance defect reconstruction and pelvic stabilization. This case series describes the utilization of advanced 3-dimensional printing and rapid prototyping technologies to construct customized acetabular components, which can be instrumental in enabling precise preoperative planning and surgical execution for these difficult acetabular cases and potentially leading to improved surgical outcomes.
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The Learning Curve From Converting From Fluoroscopic to Robotic-Assisted Direct Anterior Total Hip Arthroplasty Michael A. Masini, MD, IHA, Ann Arbor Orthopaedic Specialists, Ann Arbor, Michigan , Kara L. Sawaya, RN, BSN, Amy Harshberger, RN, BSN, Trinity Health, Michigan Heart, Ann Arbor, Michigan, Daniel Hameed, MD, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Robotic-assisted total hip arthroplasty (RA-THA) provides an alternative to fluoroscopic guidance, thus reducing radiation exposure for orthopaedic surgeons. This study was performed to assess the learning curve associated with the adoption of RA-THA using the direct anterior approach (DAA) with regard to surgical time, use of fluoroscopy, and implant placement. In addition, we compared complication rates and patient-reported outcome scores between both cohorts. A case report of an RA-THA is also presented.
Materials and Methods: This was a retrospective, non-randomized evaluation of the learning curve by assessing surgical time on a consecutive series of 89 DAA cases performed by a single surgeon. There were 53 cases that had manual THA with fluoroscopy and 36 cases with RA-THA. All cases had an acetabular component placement target of 40° inclination and 20° anteversion. An independent reviewer blinded to surgical technique used the Widmer method to measure acetabular inclination and version. Patient demographics were similar for both groups.
Results: The mean surgical time for the manual fluoroscopic group was 88 ± 21 minutes and 101 ± 14 minutes for the RA-THA group. After 15 RA-THA cases, surgical time reached time neutral compared to the manual fluoroscopic group.
The first 17 RA-THA cases utilized fluoroscopy to verify implant position until the surgeon became comfortable with the accuracy of the RA-THA system. After case 17, fluoroscopy was abandoned in all subsequent RA-THA cases. The mean radiation dose delivered to the surgical field was 5.61 ± 5.71 mGy.
Manual THA with fluoroscopy resulted in a mean acetabular inclination of 41.3 ± 4.4° and a mean anteversion of 22.4 ± 3.0°. The RA-THA resulted in a mean acetabular inclination of 42.0 ± 4.2° and a mean anteversion of 22.3 ± 3.9°. There was no noted change in RA-THA placement accuracy after case 17, when fluoroscopy was eliminated from the surgical workflow.
There were no statistical differences between the manual fluoroscopic and robotic-assisted groups with respect to complications and clinical PROM outcomes. Conclusion: The DAA THA can be performed with RA-THA and achieve comparable acetabular placement without fluoroscopy. Surgical time was higher for the RA-THA group during the learning curve, but then decreased and was consistent with the manual fluoroscopic group after 15 cases.
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Accuracy of Anterior Shoulder Injections Without Image Guidance: A Prospective Controlled Study
Pablo Dardanelli, MD, Rodrigo Brandariz, MD, Ignacio Tanoira, MD, Luciano Rossi, MD, Maximiliano Ranalletta, MD, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Introduction: This study aims to assess the accuracy of glenohumeral joint injections through an anterosuperior approach using anatomical landmarks as a guide and arthroscopic visualization as the control method and to evaluate whether there is any association between accuracy, the physicians training, and the patient’s pathology.
Materials and Methods: A sample size of 124 patients was calculated. A prospective cohort study including 164 consecutive patients was conducted. All patients over 18 years of age who underwent shoulder arthroscopy during the study period were included. A needle was placed using an anterosuperior approach before the beginning of the surgery alternating between a shoulder surgeon and a resident. Direct visualization through a posterior arthroscopic view was used to verify correct needle placement. Each case was classified as success or failure based on the arthroscopic intra-articular visualization of the needle. Univariate and multivariate analyses were performed to evaluate the relationship between injection accuracy, operator experience, and patient pathology. A p-value less than 0.05 was considered statistically significant.
Results: Of the 164 needles placed, 131 were intra-articular, giving a total correct placement rate of 80% (95% CI, 73–86%). Experts had an accuracy of 88%, compared to a precision rate of 72% for residents (p<0.001). A logistic regression was performed to evaluate which factors are independently associated with injection accuracy failure. Patients diagnosed with adhesive capsulitis had an OR of 6.15 for injection failure.
Conclusions: This study shows that an anterior-superior approach shoulder injection technique performed by a shoulder specialist without image guidance has a high precision rate. However, in physicians with no experience in shoulder surgery, as well as in some pathologies such as adhesive capsulitis, the accuracy of the procedure decreases significantly and thus, in these cases, the use of some type of image guidance during the procedure may be recommended to achieve greater precision.
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The Role of a New Hinged Total Knee Arthroplasty System for Use in a Variety of Complex Knee Scenarios: A Case Series
Daniel Hameed, MD , Michael A. Mont, MD, The Rubin Institute for Advanced Orthopaedics, Baltimore, MD, Bryan D. Springer, MD, Department of Orthopaedics, Mayo Clinic Florida, Jacksonville, Florida, Arthur L. Malkani, MD, Department of Orthopaedics, University of Louisville, Louisville, Kentucky
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Hinged knee arthroplasties are commonly used in scenarios where there are major ligament deficiencies or bone loss around the knee. They are applicable in native knees with major deformities and during revisions. They can also be used as a salvage procedure after distal femoral resection. The new modular hinged device system, namely the Triathlon Hinge Knee (THK) System (Stryker, Mahwah, New Jersey), reflects the advancements of third-generation design and enhances surgical flexibility by allowing streamlined integration with the Triathlon Total Stabilized (TS) System (Stryker, Mahwah, New Jersey) and the Global Modular Replacement System (GMRS, Stryker, Mahwah, New Jersey). Additionally, the Triathlon Revision Tibial Baseplate (Stryker, Mahwah, New Jersey) has been launched as part of THK and is compatible with the Modular Rotating Hinge (MRH , Stryker, Mahwah, New Jersey) femur, which allows the Revision Baseplate to replace the existing tibial component while leaving the existing MRH Femoral Component in place. The Triathlon Revision Tibial Baseplate enables orthopaedic surgeons to use constrained or hinged prostheses, including both distal and total femoral replacement options, without changing the Tibial Baseplate. This is because the TS, MRH, THK, and GMRS femurs are compatible with the new Triathlon Revision Tibial Baseplate. Additionally, the system can be augmented with metaphyseal cone constructs to help provide a stable foundation for reconstruction. This report explores the application of a new modular hinged device system in various scenarios, starting with (1) complex primary hinged knee arthroplasty, followed by revision hinged knee arthroplasty cases including (2) failed TKA with medial collateral ligament (MCL) dysfunction, (3) severe arthrofibrosis post-TKA, (4) revisions for prosthetic joint infection, (5) extensor mechanism deficiency, and (6) arthrofibrosis with extensor mechanism disruption, concluding with a case of (7) distal femoral arthroplasty for periprosthetic fracture post-failed TKA.
The Growing Role of Artificial Intelligence and Technology in Hip and Knee Arthroplasty
Joshua Rainey, MD, Jeremy M. Gililland, MD, Associate Professor, University of Utah, Salt Lake City, Utah, Nipun Sodhi, MD, Northwell Health, Riverhead, New York, Michael A. Mont, MD,Sinai Hospital of Baltimore, Baltimore, Maryland
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Artificial intelligence and technology have continued to evolve over recent decades, and their utility in hip and knee arthroplasty is growing with interest and enthusiasm. A multitude of technologies are available to assist surgeons in the intraoperative execution of hip and knee arthroplasty, ranging from robotics and augmented reality to artificial intelligence-powered fluoroscopy. The purpose of this review is to provide a framework for arthroplasty surgeons to understand the concept of artificial intelligence and the advancements in technologies that impact the perioperative care of patients undergoing hip and knee arthroplasty.
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Direct Anterior Total Hip Arthroplasty with VELYS™ Hip Navigation
Sean E. Slaven, MD, Walter Reed National Military Medical Center, Bethesda, MD, Alexander V. Strait, MS, William G. Hamilton, MD, Anderson Orthopaedic Research Institute, Alexandria, Virginia
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We describe the technique of total hip arthroplasty via a direct anterior approach using the Depuy Synthes (Raynham, MA) VELYS™ Hip Navigation system This technique allows one to accurately set the acetabular component position as well as recreate leg length and offset to meet the goals of hip reconstruction in a precise and efficient manner.
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