Surgical Technology International
45th Edition
ISSN:1090-3941
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Patient-Reported Outcome Measures in the Repair of Chondral Defects: How Well Do the Scores Relate to Each Other?
Justus Gille, Prof. Dr., Martin Nauroz, MD, Regio Kliniken, Hamburg, Germany, Eric Reiss, MD, OrthoPraxis, Zofingen, Switzerland, Jan Schagemann, Prof. Dr., Orthopaedics and Trauma Surgery, Coesfeld, Germany, Sven Anders, Assistant Professor, University of Regensburg, Asklepios Clinical Center Bad Abbach, Bad Abbach, Germany, Thomasz Piontek, Prof. Dr., University of Medical Sciences, Poznan, Poland
1814
Introduction: In the repair of focal chondral defects, there are several patient-reported outcome measures (PROMs) that are used to assess the patient’s well-being. However, the question remains as to how well one scoring system relates to another, which may restrict the comparison of results from different studies. Therefore, we examined the strength of correlations between the Lysholm and KOOS scores.
Materials and Methods: The data for this analysis was obtained from the Autologous Matrix-Induced Chondrogenesis (AMIC®; Geistlich Pharma AG, Wolhusen, Switzerland) knee registry, which is an ongoing, multicentre database designed to record changes over time in knee function and symptoms. This is done using the Lysholm score, the Visual Analogue Scale (VAS) for pain, and the five domains of the Knee injury and Osteoarthritis Outcome Score (KOOS). All patients had preoperative and postoperative scores at one-year follow up. The results were evaluated using the Spearman’s rank correlation test.
Results: We identified 79 patients in the registry, all of whom were treated by the co-authors and had preoperative scores and postoperative scores at one year for the Lysholm, VAS, and the KOOS domains. The Lysholm score demonstrated a significant correlation (p <0.0001) to all KOOS domains. The correlation coefficients were 0.81, 0.82, 0.83, 0.84, and 0.76 for the KOOS domains of symptoms, pain, activities of daily living (ADL), quality of life (QoL), and Sport, respectively. The correlation between VAS pain and the KOOS domain for pain was significant (p <0.0001) but notably lower, with a correlation coefficient of 0.71.
Conclusion: Our data provides evidence that the outcome of the Lysholm knee score is strongly correlated with the KOOS scores, with the KOOS domains of ADL and pain exhibiting the highest correlation. Thus, it may be possible, through formulae calculations, to predict a KOOS score from the Lysholm score. With regard to assessment of outcomes over larger numbers of studies, the pooling of substantially more data could facilitate the conduct of systematic reviews and meta-analyses pertaining to the surgical treatment of chondral injuries of the knee.
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Mako Robotic-Arm Assisted Total Knee Arthroplasty: Updated Software
Robert Marchand, MD, South County Orthopedics, Wakefield, Rhode Island, Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Maryland, Daniel Hameed, MD, Michael A. Mont, MD, LifeBridge Health, Sinai Hospital of Baltimore, Nathan Angerett, DO, Orthopaedic Institute of Pennsylvania, Harrisburg, Pennsylvania, Laura Scholl, MS, Implant and Robotic Research, Stryker, Mahwah, New Jersey
1817
Recently, robotic-arm assisted total knee arthroplasties have become popular because of their promise to lead to enhanced accuracy and efficient planning of the procedure, as well as improved radiographic and clinical outcomes. One robotic system is based on computed tomography (CT) to help with preoperative planning, intraoperative adjusting, and bone cutting for these procedures. The purpose of this article is to describe the second-generation iteration of this CT-based robotic technique by describing the new features using an actual total knee arthroplasty case. This article then becomes a step-by-step guide to performing the procedure, as well as describing the new features of this upgraded system.
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Treatment Journey for Nonoperative Symptomatic Knee Osteoarthritis: Data from a New Real-World Registry
Andrew I. Spitzer, MD, Cedars Sinai Medical Center, Los Angeles, California, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Jennifer H. Lin, PhD, Pacira BioSciences, Inc., Tampa, Florida, Vinod Dasa, MD, Louisiana State University Health Services Center, New Orleans, Louisiana, Adam Rivadeneyra, MD, Orthopaedic Specialty, Institute, Orange, California , David Rogenmoser, DO, Mid State Orthopaedic & Sports Medicine Center, Alexandria, Lousiana, Andrew L. Concoff, MD, Rheumatology, Exagen Inc., Vista, California, Mitchell K. Ng, MD, Maimonides Medical Center, Brooklyn, New York , Mary DiGiorgi, PhD, MPH, Stan Dysart, MD, Pacira BioSciences, Inc., Tampa, Florida, Joshua Urban, MD, OrthoNebraska, Omaha, Nebraska, William M. Mihalko, MD, PhD, University of Tennessee Health Science Center, Campbell Clinic Orthopaedics, Memphis, Tennessee
1860
Introduction: There is a wide range of nonoperative options to manage symptomatic knee osteoarthritis (OA). This paper aimed to 1) define the treatment sequence for patients undergoing up to four subsequent rounds (i.e., cryoneurolysis) of superficial (Cryo-Superficial) and/or deep genicular nerves (Cryo-Deep/Both), intra-articular corticosteroid injections (IA-CS), triamcinolone extended-release (IA-TA-ER), hyaluronic acid (IA-HA), or non-steroidal anti-inflammatory drugs (IA-NSAIDs); 2) compare usage of extended-release versus standard corticosteroid injections; and 3) quantify distribution of repeated treatments.
Materials and Methods: We identified 502 patients with symptomatic knee OA and received nonoperative intervention within the Innovations in Genicular Outcomes (IGOR) registry from 2021 to 2024. Treatment journey during follow up was presented aggregating baseline patient demographics, along with sequence of nonoperative treatments per patient, duration, and frequency of repeated use. Repeated use of Round 1 treatment for subsequent treatment rounds was estimated with descriptive statistics.
Results: Fifty-three percent of patients received only the original Round 1 treatment option, either single/repeated dose and did not receive any alternative treatment. Seventy-three percent of patients treated with intra-articular extended-release triamcinolone (IA-TAER) repeated the treatment at least once, whereas 60% of those treated with other treatments did so. No adverse events were reported in patients during repeated treatments.
Conclusion: Patients who received IA-TAER were more likely to repeat the same injection, with 73% repeating at least once and no adverse events were attributed to repeated injections. Approximately half of the patients have switched from the initial treatment offered during follow up, with the use of IA-TAER associated with higher rates of repeated treatment.
Significance and Innovation
1. Our study used a newly developed real-world registry IGOR to characterize treatment progression for patients with symptomatic knee OA undergoing up to five rounds of nonoperative treatment. 2. Non-surgical interventions included cryoneurolysis, intra-articular injections of NSAIDs, hyaluronic acid injections, corticosteroid, or extended release steroid (triamcinolone) injections. 3. We found 73% of patients treated with intra-articular extended-release steroid injections repeated treatment at least once, relative to 60% by other treatments. 4. We found approximately half of patients switched from initial treatment offered during follow up, with the use of IA-TAER associated with higher rates of repeated treatment.
Favorable Early Patient-Reported Outcome Measures and Clinical Retear Rates in High-Risk Rotator Cuff Repairs Augmented with a Reinforced Bio-Inductive Implant at One-Year Follow Up
Sean McMillan, DO, Chief of Orthopedics, Virtua Our Lady of Lourdes & Virtua Willingboro Hospitals, Elizabeth Ford, DO, Orthopedic Surgeon, Inspira Health Network, Vineland, New Jersey, Shariff K. Bishai, DO, MS, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
1819
Introduction: The purpose of this article is to examine the risk of early clinical rotator cuff repair failures in high-risk patients who were augmented with a reinforced bio-inductive implant (RBI).
Materials and Methods: A retrospective chart review was performed identifying full-thickness rotator cuff repairs (RCR) augmented with an RBI. Inclusion criteria for “high risk of retear” were: large (>3cm) and massive (>5cm, >/= 2 tendons) tears, anterior to posterior (AP) tear >2.5cm, infraspinatus fatty atrophy (Goutalier >/= 2), recurrent tears, and at least one comorbidity (diabetes, hypertension, active smoker). ROM, VAS, and ASES scores were collected at preoperative, three-month, six-month, and 12-month visits. Clinical failures were defined as complete retear based upon imaging, repeat rotator cuff surgery, VAS score >5 at one-year postoperative, and ASES MCID <27-point improvement.
Results: Forty-nine patients were found to have undergone RCR with an RBI augmentation. Mean follow up was 26.1 months. Clinical healing rate was 94% (46/49). The need for surgical intervention post RCR was 8.2% (4/49). The complication rate was 14.3% (7/49). VAS scores at three, six, and 12 months compared to preop revealed statistically significant decreases at all timepoints (D-3.9, D-4.6, D-5.2, respectively, p<0.001). ASES scores at three, six, and 12 months compared to pre-surgical scores met the MCID and were found to have statistically significant improvements at all timepoints (D30.7, D40.8, D49.8, respectively, p<0.001). Shoulder ROM (forward flexion/abduction) at three, six, and 12 months compared to preop was found to be statistically significant at all timepoints (p<0.01).
Conclusion: The addition of an RBI to RCR in patients at high risk of failure demonstrated favorable outcomes in terms of range of motion, pain, and functional outcome scores with a low rate of clinical retear at a minimum of one-year follow up. Clinical Relevance: Many risk factors have been attributed to high retear rates and poor clinical outcomes in patients undergoing RCR. Numerous variations to RCR have been explored to aid in outcomes and decrease failures. This manuscript is the first to examine the use of an RBI as an RCR augment. The implant’s bio-inductive properties and strength profile demonstrate promising benefits at early timepoints in this study, indicating that it can improve patient-reported outcomes while decreasing clinical failures in patients at high risk of retear.
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Equivalent Six-Week Knee Motion and Patient-Reported Outcome Scores After Cementless and Cemented Total Knee Arthroplasty with a Kinematic Alignment Optimized Implant Muzammil Akhtar, BS, California Northstate University, Elk Grove, California, Stephen M. Howell, MD, Maury L. Hull, PhD, Professor, University of California Davis, Davis, California, Alexander J. Nedopil, MD, Lehrstuhl für Orthopädie der Universität Würzburg, Würzburg, Germany
1859
Introduction: Cemented kinematic alignment (KA) total knee arthroplasty (TKA) is popular due to its superior patient-reported outcome scores (PROs). A new cementless version of a KA-optimized implant is available. The femoral component features a 20° trochlear groove and medial spherical articulation. The tibial insert features a medial socket, creating native anterior-posterior stability and a lateral flat articular surface promoting native medial pivot rotation. The present study aimed to determine whether clinical outcomes for patients receiving the cementless KA-optimized implant are equivalent to those receiving the cemented version after six weeks. This comparison is essential because lower PROs could indicate delayed osteointegration of the components, like dysfunction associated with delayed fracture union.
Materials and Methods: The study included 95 cementless KA TKAs matched 1:1 with 95 cemented KA TKAs based on surgery date, age, preoperative knee deformity, sex, and surgeon. Patients completed the Oxford Knee Score (OKS) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) both preoperatively and at six weeks, as well as the Forgotten Joint Score (FJS) at six weeks. A Wilcoxon two-sided equivalence test was used to test the null hypothesis that results were comparable for the cementless and cemented KA TKAs.
Results: The analysis included 114 females and 76 males, with a mean age of 68 years and a body mass index (BMI) of 31kg/m². Preoperatively and at six weeks, the age, sex distribution, BMI, knee extension and flexion, OKS, and KOOS JR scores for cementless and cemented KA TKAs were equivalent. At six weeks, the FJS scores were also equivalent.
Conclusion: The KA-optimized implant closely resembling native knee morphology did not show evidence of delayed osteointegration. After six weeks, knee motion and PROs were equivalent to those of the cemented implants. However, longer-term monitoring of this new cementless implant is necessary.
Robotic Total Knee Arthroplasty is Associated with Thinner and Less Constrained Polyethylene Inserts
Travis R. Weiner, BS, William K. Crockatt, MD, Roshan P. Shah, MD, Associate Professor, Jeffrey A. Geller, MD, Associate Professor, Alexander L. Neuwirth, Associate Professor, H. John Cooper, MD, Associate Professor, Columbia University Medical Center, New York, New York
1821
Introduction: Accurate pre-resection assessment of gap measurements during total knee arthroplasty (TKA) may reduce the need for thicker polyethylene inserts or those with higher constraint by allowing the surgeon to address potential imbalance through guiding bony resections and implant position. This study aimed to determine whether robotic assistance with pre-planning allowed for the use of thinner and less-constrained polyethylene inserts compared to conventional methods.
Materials and Methods: Records were retrospectively reviewed for 408 patients who underwent primary TKA. Patients were divided into cohorts based on the technique utilized—conventional, manual methods with a jig-based system (CM-TKA, 169 knees) versus robotic-assisted TKA (RA-TKA, 237 knees). Operative notes were reviewed for implant brand, thickness of the polyethylene insert, degree of constraint of the polyethylene insert, and whether robotic assistance was used to complete the operation. Statistical analysis was performed using Chi-square tests for categorical and t-tests for continuous variables.
Results: There were no significant differences in demographic characteristics between the RA-TKA and CM-TKA groups. Statistically significant differences were observed between cohorts in mean polyethylene insert thickness (11.0mm ± 1.3mm vs. 11.7mm ± 1.7mm, p<0.0001), rate of use of the thinnest 10mm insert (43% vs. 34%, p=0.048), rate of “outlier” insert sizes ≥14mm (5% vs. 18%, p<0.0001), and rate of constrained insert use (4% vs. 18% of knees, p<0.0001).
Conclusion: In a review of 408 consecutive TKA patients, use of robotic-assisted techniques allowed for the use of thinner polyethylene inserts, fewer “outlier” polyethylene sizes, and reduced need for constrained inserts compared to conventional, manual methods.
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Robotic-Arm Assisted THA: Improved Acetabular Component Accuracy and Patient-Reported Outcome Measures
Benjamin F. Giertych, MD, Adam E. Klein, MD, Associate Professor, Matthew J. Dietz, MD, Professor, Benjamin M. Frye, MD1, Associate Professor, West Virginia University, Morgantown, West Virginia, Brock A. Lindsey, MD, Associate Professor, Johns Hopkins University, Baltimore, Maryland
1823
Introduction: Acetabular component placement is critical for total hip arthroplasty (THA) stability and clinical outcomes. We investigated cup placement with robotic-arm assisted (RA) and conventional manual (CM) THA and compared patient-reported outcome measures (PROMs) and dislocations.
Materials and Methods: Thirty-seven patients were randomized to undergo RA or CM primary THA. Computed tomography scans were completed preoperatively and at three months. Component version and inclination were analyzed with target anteversion of 20° and inclination of 40°. PROMs were collected to assess early clinical outcomes.
Results: Seventeen RA and 20 CM THAs were performed. Overall, 1/17 RA and 8/20 CM components fell outside the Lewinnek safe zone. No RA components fell outside the safe zone for inclination and one did for version. Three CM components were outside the inclination safe zone and six were outside for version. There were no dislocations in either group. Improvements in all Hip Disability and Osteoarthritis Outcome Score (HOOS) subtype scores reached substantial clinical benefit thresholds in both groups. One-year HOOS symptom and sports score improvements were significantly higher in the RA group. PROMIS-10 mental health improvement was significantly higher in the CM group at six months, but not at one year.
Conclusions: Robotic-arm assistance may result in more consistent placement within the Lewinnek safe zone. There were improvements in PROMs in both groups, but there were different effects on individual PROMS between groups. Further study is necessary to determine the clinical significance of these improvements.
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The Effect of Sensor-Based Rehabilitation (SR) on Chronic Knee Pain (CKP) Outcomes—A Systematic Review and Meta-Analysis (SRMA)
Leeu Jun Jie, MBBS, Tao Xinyu, MBBS, Angeline Ai Ling, AW, MBBS, Hamid Rahmatullah, BIN ABD RAZAK, MBBS, MMed (Orth), FRCSEd (Orth), Adjunct Associate Professor, Sengkang General Hospital, Sengkang, Singapore
1829
Introduction: This study aims to evaluate the effect of sensor-based rehabilitation (SR) on chronic knee pain (CKP) outcomes.
Materials and Methods: PubMed, Embase, CINAHL, SCOPUS, Cochrane Library, grey literature, and bibliographic references were searched from inception to April 2023. Only randomized controlled trials (RCTs) and cohort studies evaluating the outcomes of SR on CKP were included. Inclusion and exclusion criteria were based on type of study, research subjects, intervention, outcome, language, and availability of data. Out of 937 studies screened, a total of 10 studies with 4347 patients met selection criteria. Comparison of outcomes following intervention was conducted across studies. Meta-analysis of KOOS subscales was also conducted. Literature retrieval and data extraction were conducted by three independent reviewers. Two reviewers performed quantitative data extraction independently before compilation and cross-referencing on Covidence with a third researcher assisting in the cross-referencing process independently to minimise judgment errors.
Results: The sensors utilized included wearable sensors, plantar-controlled sensors, embedded sensors, and optical sensors. There was a high degree of variability in the conduct of the intervention programs and timepoint of assessment. There was an improvement in the KOOS aggregate scores from baseline to post intervention with better improvements seen in studies incorporating avatar-based biofeedback. However, meta-analysis of the KOOS subscales did not show clinically significant differences between control and intervention groups.
Conclusion: There is insufficient evidence to support the routine use of SR in patients with CKP. However, there is some evidence to suggest that incorporation of SR with avatar-based biofeedback in a multi-faceted treatment approach may yield better outcomes than the use of sensors as merely activity trackers.
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Arthroscopic Partial Meniscectomy Using a Needle Arthroscope for Visualization Resulted in Greater Retention of Postoperative Quadriceps Muscle Strength Compared to Traditional Arthroscope
Elizabeth Ford, DO , Dylan Chayes, DO, Inspira Health Network, Vineland, New Jersey, Manuel Pontes, PhD, Professor, Rowan University, Glassboro, New Jersey, Sean McMillan, DO, Virtua Health System, Marlton, New Jersey
1830
Introduction: The purpose of this study is to prospectively evaluate differences in post-arthroscopic partial meniscectomy patients based upon the use of a small-bore needle arthroscope or traditional arthroscope for intraoperative visualization.
Materials and Methods: Sixty-eight patients were randomized in a 1:1 fashion to have the visualization for arthroscopic partial meniscectomy performed with either a needle arthroscope or traditional arthroscope. Prior to surgery and one-week post procedure, patients underwent peak torque isometric knee extension testing using a handheld dynamometer and Visual Analog Scale (VAS) score collection. The intraoperative arthroscopic fluid volume used was collected. Exclusion criterion included: age under 18, non-English speaking, Kellen-Lawrence Grade 3 or higher, previous ipsilateral knee surgery within six months, and any patient in which arthroscopic partial meniscectomy (APM) was not considered the primary surgical procedure. Tourniquet was not utilized for either study group.
Results: Two group comparisons were performed between patients in the needle arthroscope (NA) group (n=34) and patients in the traditional arthroscope (TA) group (n=34). For the operated knee, patients in the NA group had greater postop leg strength (lbs) (24.7 vs. 18.5, t=3.76, p<0.001) and a smaller decrease in leg strength after surgery (-2.8 vs. -8.7, t=9.96, p<0.001). In contrast, results also showed that the leg strength of the non-operated leg was higher postop in both the NA group (0.6, p<0.001) and TA (0.8, p<0.001) arthroscopy group. Significantly less arthroscopic fluid was required for completion of the procedure in the NA group (479 ml) compared to patients in the TA group (2,568ml t=-38.51, p<0.001). Mean VAS score was significantly lower in the NA group (2.5) versus the TA (M=3.1, t=-3.25, p=0.002). The reduction in VAS pain scores was lower in the NA group (M=-1.8) versus the TA group (M=-1.1, t=-3.45, p=0.001).
Conclusion: The use of a small-bore needle arthroscope for visualization during arthroscopic partial meniscectomy is associated with improved retention of quadriceps function and less postoperative pain in the early postoperative period compared to a traditional arthroscope.
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Assessing Total Knee Arthroplasty Implant Balance with a Passive Knee Drop Test
Kevin Abbruzzese, PhD, Sally LiArno, PhD, Stryker, Joint Replacement, Mahwah, New Jeresey, Michael Dunbar, MD, Professor, Dalhousie University, Halifax, Canada, Jared Weir, MD, Weir Orthopedics, Saginaw, Michigan, Stefano Bini, MD, Professor, University of California San Francisco, San Francisco, California, Sean B. Sequeira, MD, Medstar Union Memorial Hospital, Baltimore, Michael A. Mont, MD, Sinai Hospital of Baltimore, Maryland
1838
Introduction: Soft-tissue balancing is a critical component of total knee arthroplasty (TKA), though most current modalities to evaluate this intraoperatively are subjective and based upon empiric observation. A modified pendulum knee drop (PKD) technique has been developed to quantitatively evaluate knee joint soft-tissue stiffness. By measuring the amplitude and decay rate of oscillations when the leg is passively swung from extension to flexion, the modified PKD test offers a novel approach to evaluating knee stiffness in a reproducible manner. The purpose of this study was to explore the ability of the modified PKD test to quantify changes in stiffness induced by insert thickness in a cadaveric TKA model.
Materials and Methods: There were eleven (N=11) fresh frozen cadaver specimens that underwent a robotic-assisted total knee arthroplasty (RATKA) procedure. Nine of the 11 specimens underwent an RATKA with a cruciate-retaining (CR) femoral implant, and the remaining two specimens underwent an RATKA with a posterior-stabilized (PS) implant. The modified PKD test was performed on each RATKA specimen, where a planned insert was targeted to achieve an anatomically balanced knee and then increased by 2mm increments to simulate stiffer knee joints (in two cases, an additional 2mm insert was utilized for a total 4mm increment). An inertial measurement unit (IMU) sensor was placed on the tibia to record the range of motion (ROM). The thigh of the specimen was abducted over the side of the surgical table and positioned parallel to the floor to allow the shank to oscillate freely. The knee was then flexed to 45 degrees, calibrated in this reference position, and released, allowing the joint to oscillate until coming to rest. The procedure was repeated three times for each of the insert thicknesses. The IMU sensor was used to measure knee ROM, and the log-decrement ratio was calculated for each condition to estimate knee stiffness and was averaged over the three trials. The data was normally distributed, and paired sample t-tests were used to assess significance within specimens. Stiffness ratios were calculated as the log-decrement values of the thickest tibial inserts divided by the log-decrement value of the thinnest tibial inserts and were used to estimate the magnitude of stiffness increases.
Results: The modified PKD was able to detect the increased stiffness caused by increasing insert thickness in all specimens. This increase in stiffness was not impacted by implant design or implant size. The modified PKD test was able to reproducibly demonstrate an increase in stiffness when the same specimen was trialed with 2 to 4mm thicker polyethylene inserts. The modified PKD demonstrated reproducible results with respect to log decrement estimations, with an average standard deviation of 0.02 for all trials.
Discussion: This study investigated the ability of a modified PKD test to quantify the relative change in the stiffness of a TKA when changing the thickness of tibial inserts. Comparing the stiffness ratios between test constructs demonstrated that the modified PKD test was sensitive to variations in stiffness caused by thicker implants. A significant increase in knee stiffness was observed with as little as a 2mm incremental insert thickness, resulting in nearly twice the stiffness of the TKA, as documented by the increase in log decrement ratios. The lack of impact on implant size or design type suggests that these variables, when the TKA is appropriately sized and the procedure appropriately performed, do not impact stiffness. The ability of the modified PKD test to produce a sensitive and reproducible measure of relative construct stiffness is a promising new tool to help the surgeon in the operating room assess appropriate insert thickness for soft-tissue balancing.
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Does the ArthroSim™ Shoulder Simulation Discriminate Between the Novice and Expert User? An External Validation Study of the ArthroSim™ Shoulder Arthroscopy Simulator
Zafar Ahmad, MD, Adjunct Professor, University of Arizona, Phoenix, Arizona, Faisal Mehmood, MD, Honor Health, Phoenix, Arizona, Samuelson E. Osifo, MD, Yale University, New Haven, Connecticut, Ali Noorani, FRCS, Kash Akhtar, FRCS, Royal London Hospital, London, United Kingdom
1722
Introduction: Our aim is to investigate the face validity and the construct validity of the ArthroSim™ virtual reality shoulder arthroscopy simulator (Touch of Life Technologies, Inc., Aurora, Colorado).
Materials and Methods: Fifteen doctors participated, with five from each of the following levels: novice with no arthroscopies performed, intermediate with less than 50 arthroscopies performed, and expert with over 100 arthroscopies performed. They first undertook a simulation task on the ArthroSim™ simulator, with the simulation and their body movements recorded. Each participant then completed a Likert scale questionnaire after their simulation task evaluating the face validity of the machine. The video recordings were rated by two shoulder surgeons independently using the Global Rating Scale for Shoulder Arthroplasty (GRSSA), Arthroscopic Surgical Skill Evaluation Tool (ASSET), and Imperial Global Arthroscopy Rating Scale (IGARS) scoring systems for construct validation.
Results: All three scales demonstrated high internal consistency GRSSA (0.976 ), ASSET (0.980), and IGARS (0.979). The intraclass correlation coefficient demonstrated high agreement between the assessors: GRSSA (0.88), ASSET (0.90), and IGARS (0.89). Construct validity was evaluated using Kruskal-Wallis one-way analysis of variance: GRSSA (chi square test: 19.828; p<0.001); ASSET (chi square test: 19.62; p<0.001); and IGARS (chi square test: 19.63; p<0.001). This demonstrates that the three scoring systems distinguish significantly between participants with different levels of experience utilizing a virtual reality simulator.
Conclusion: Our study has shown that the ArthoSim™ simulator can accurately distinguish between experience level of the participants. It is more effective in reproducing a training environment as reality for less experienced surgeons. All participants agreed that it is valuable in developing surgical training for the novice and intermediate skill level.
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Modern Plasma Medicine and Orthopaedic Surgery: A Brief History and Outlook
Moritz J. Sharabianlou Korth, BS, Robert Manasherob, PhD, Sankalp Mrutyunjaya, BS, Pier F. Indelli, MD, Associate Professor, Nicholas J. Giori, MD, PhD, Professor, Derek F. Amanatullah, MD, PhD, Stanford University, Redwood City, California, Associate Professor, Abiram Bala, MD, Los Angeles Medical Center, Los Angeles, California
1840
Modern plasma medicine is a field of medical research combining plasma physics, life sciences, and clinical medicine. It aims to achieve direct application of physical plasma on or in the human body for therapeutic purposes. In medical contexts, the term plasma denotes the liquid component of blood, while in the physical sciences, it refers to ionized gas—also known as the fourth state of matter alongside solid, liquid, and gas. The biological effects of plasma are based on various mechanisms, involving synergistic actions of reactive species such as ionized argon gas molecules and ultraviolet light. Cold-atmospheric plasma (CAP), a specific subtype of plasma, maintain temperatures below 104°F/40°C at the application point, allowing plasma treatment on living tissue at tissue tolerable temperatures. The invention of CAP generating devices has expanded the possibilities for clinical application of plasma in medicine, with growing evidence supporting its efficacy in bacterial load reduction and potential biofilm eradication through debridement. Its antimicrobial effect, coupled with minimal adverse effects on healthy cells, positions it as a promising alternative or additional therapy option. This review provides an overview of current clinical applications of plasma medicine and explores potential roles for plasma application in orthopaedic surgery.
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Osteonecrosis of the Femoral Head: Core Decompression Systems
Innocent Njoku, MD, Ignacio Pasqualini, MD, Nickelas Huffman, BS, Shujaa T. Khan, MD1, Benjamin E. Jevnikar, BA, John P. McLaughlin, DO, Nicolas S. Piuzzi, MD, Matthew E. Deren, MD, Cleveland Clinic, Cleveland, Ohio, Michael A. Mont, MD, Sinai Hospital, Baltimore, Maryland
1845
Osteonecrosis of the femoral head (ONFH) is a chronic progressive debilitating disease that often affects young and active patients. It results from vascular interruption to the femoral head and can be caused by trauma, chronic corticosteroid use, chronic alcoholism, and coagulopathies. Treatment includes core decompression, a surgical procedure that may help delay or forestall disease progression if performed at the early stages of the disease. Technological advances have made the procedure more efficient and effective. There are several core decompression systems available in the market, giving healthcare providers options for core decompression technique: (1) The PerFuse™ Percutaneous Decompression System (Zimmer Biomet, Warsaw, Indiana) offers the advantage of utilizing autologous stem cell progenitor augmentation which has been shown to provide clinical benefits to patients; (2) The Advanced Core Decompression System (Stryker, Kalamazoo, Michigan) utilizes synthetic regenerative bone grafts, and these calcium-based synthetic grafts are well-accepted as the adjuvant modality for small defects; and (3) The Avascular Necrosis/Osteonecrosis Core Decompression Expandable Reamer System (Arthrex Inc., Naples, Florida) offers the unique ability for endoscopic-assisted core decompression, which may provide increased ability to treat early-stage ONFH by identifying necrotic lesions not visible radiographically. The preferred management of ONFH remains a topic of controversy and is reliant on the disease stage. Future randomized clinical trials comparing various core decompressions systems, with or without the use of bone marrow aspirates and arthro-endoscopy, may provide insight into the true clinical benefits of each method.
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Robotic-Assisted Medial Unicompartmental Knee Arthroplasty in an Outpatient Setting
Trisha Patel, BS, Jumaa Baker, BS, Allison Eberhard, BS, Eyal Ginesin, MD, Ronak M. Patel, MD, Illinois Center for Orthopaedic Research & Education (iCore), Hinsdale, Illinois
1844
There were 63 outpatient medial unicompartmental knee arthroplasties (UKAs) performed by Mako robotic assistance by six surgeons. There were 40 men and 23 women who had a mean age of 65.1 years (range, 38 to 80). Their mean body mass index (BMI) was 29.6 (range 21.8 to 39.2), and 28 patients had a BMI over 35. Overall, patient perceptions of the procedure were excellent (mean 9.2 rating of 10), which was not different by sex or body mass index. There were no 30-day complications or readmissions. At one year, there was one case revised for maltracking, resulting in a revision rate of 1.6% (1 out of 63 patients) with no cases of aseptic loosening. There were two other patients that had minor procedures (nerve ablation and removal of a loose body). The results of this prospective study confirm that outpatient robotic-arm assisted medial UKA is safe and feasible with a positive patient perspective of the procedure.
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Does Fluoroscopic-Aided Enabling Technology Improve Acetabular Component Position and Reduce Radiation Exposure in Direct Anterior Total Hip Arthroplasty?
David A. Crawford, MD , Todd E. Bertrand, MD, MBA, Adolph V. Lombardi, Jr., MD, FACS, Keith R. Berend, MD, JIS Orthopedics Inc., New Albany, Ohio, Jacob Alexander, MD, The University of Toledo College of Medicine, Toledo, Ohio
1848
Accurate acetabular component positioning is crucial for the success of total hip arthroplasty (THA). Malplacement of the acetabular component increases the risk of post-surgery complications, most notably dislocation.1 Furthermore, malposition can also result in wear of the polyethylene liner, limited range of motion, and osteolysis.2,3 These complications have led to controversy regarding the optimal acetabular component position.
The historic Lewinnek “safe zone” defines the ideal acetabular placement as within 40° +/- 10° abduction and 15° +/- 10° anteversion.4 However, recent controversy has emerged regarding the ideal placement of the acetabular component with one systematic review showing acetabular components placed within the Lewinnek parameters having no significant difference in dislocation rate to those components placed outside the “safe zone.”5 Callanan et al. found that a range of 30–45° of abduction and 5–25° of anteversion was the ideal target zone while other studies have argued that the historic safe zone, while useful, should not be considered completely protective against dislocations.6,7 In addition, the spinopelvic relationship as it relates to changes in acetabular cup orientation from a standing to seated position may alter cup placement from the “ideal” position to accommodate reduced spinopelvic junction motion and limit the risk of postoperative instability.8
Secondary to risk of acetabular cup malposition during THA, fluoroscopically aided enabling technology (FET) has gained popularity recently, secondary to proposed benefits of improved accuracy of intraoperative component positioning over standard landmark identification or the use of fluoroscopy alone (FA), as well as minimizing the risk of significant postoperative leg length discrepancies.9,10 In addition, further factors such as not needing special preoperative imaging, minimal change to workflow or surgical approach, and the possibility of reduced operative times have made the use of this technology appealing.11
In addition to the debate regarding ideal acetabular component position to reduce postoperative complications, there has been ongoing discussion regarding the potential detrimental effects of cumulative radiation dose to the surgeon, patient, and operating room personnel when using fluoroscopy for placement of the acetabular component in direct anterior approach total hip arthroplasty (DAA-THA). Prior studies have shown that during DAA- THA, average radiation time was 15.1 seconds (secs), and exposure was 2.00mGy with increasing exposure seen as patient body mass index (BMI) increased.12,13 In theory, FET may help to reduce radiation exposure through less use of intraoperative fluoroscopy for confirmation of acetabular component position.
The questions proposed in this study are: 1) Does FET improve the accuracy of acetabular component position versus FA in DAA-THA? and 2) Does FET reduce fluoroscopy time and radiation exposure compared to FA in DAA-THA, and is this dependent upon the BMI of the patient?
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Excellent Outcomes in Obese Patients Following Cementless Robotic-Assisted Total Knee Arthroplasty
Matthew L Magruder, MD, Maimonides Health, Brooklyn, New York, Tanner McClure, DO, Kevin Marchand, BS, Robert C Marchand, MD, Ortho Rhode Island, Warwick, Rhode Island , Michael A Mont, MD, Professor, Rubin Institute of Advanced Orthopaedics, Baltimore, Maryland
1849
Introduction: The results of cementless robotic-assisted total knee arthroplasty (RA-TKA) have not been evaluated in obese patient populations. The purpose of this study was to evaluate the rates of aseptic loosening, patient-reported outcomes, and surgical complications of cementless RA-TKA cases in obese and nonobese patient cohorts.
Materials and Methods: A retrospective review between 2018 to 2021 of a single-surgeon series was conducted, producing 1,546 patients. Patients were categorized as either obese (body mass index [BMI] <35) or nonobese (BMI <35), generating 472 and 1,092 patients, respectively. The average BMI was 40.5 (range, 35.0 to 64.1) in the obese group and 28.6 (range, 16.5 to 34.9) in the nonobese group. The primary outcome was the rate of aseptic loosening. Secondary outcomes included patient-reported outcomes, comprising Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS JR) scores, and the reduced Western Ontario and McMaster Universities Arthritis Index (r-WOMAC) scores. Charts were reviewed to establish rates of postoperative surgical complications. Significance tests were conducted using either t-tests or Chi-squared independence tests, and a p-value of <0.05 was considered significant.
Results: There were no cases of aseptic loosening in the obese or nonobese cohorts, making survivorship 100% for both. While preoperative KOOS JR and r-WOMAC scores were significantly worse in the obese group, they were not statistically significant at either six-week or 12-month timepoints. The obese cohort had statistically greater improvements in r-WOMAC total scores at six weeks and 12 months; they also had statistically significant superior improvement in KOOS JR at 12 months. There were no statistically significant differences in postoperative surgical-related complications.
Conclusion: We demonstrated that rates of aseptic loosening and patient-reported outcomes in obese patients undergoing RA-TKA are excellent, and patient-reported outcomes demonstrated superior improvement in the obese cohort compared to those in the non-obese cohort.
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An Insert Goniometer Identifies One Insert Thickness That Provides Maximum Tibial Rotation During Kinematically Aligned TKA Using a Medial Parapatellar Approach
Jacob R. Hinkley, Orthopedic & Sports Medicine Center, Elkhart, Indiana, Alexander J. Nedopil, Adjunct Professor, König-Ludwig-Haus, University of Würzburg, Würzburg, Germany, Keith R. Berend, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio
1854
Introduction: A surgeon performing kinematically aligned total knee arthroplasty (KA TKA) through a mid-vastus approach can use an insert goniometer to select the optimal insert thickness. The insert goniometer provides the value of soft-tissue-driven tibial internal rotation during passive knee flexion. This study tested whether the insert goniometer can identify one insert thickness that maximizes tibial rotation while restoring full knee extension during KA TKA performed through a medial parapatellar approach.
Materials and Methods: One surgeon trialed goniometer inserts from a 10 to 14mm thickness with a medial ball-in-socket and flat lateral articular conformity in 33 patients treated with unrestricted caliper-verified KA, PCL retention, and a medial parapatellar approach. The medial insert had markings that measured tibial orientation relative to a sagittal line on the femoral trial component at full extension and 90° flexion (+ external/ - internal). The difference of tibial external orientation in extension and tibial internal orientation at 90° flexion computed tibial internal rotation.
Results: Of the 33 TKAs, a 10mm (N =13) or 14mm thick (N =2) insert maximized tibial internal rotation. In these TKAs, a 1mm thinner or thicker liner was not trialed, respectively. The remaining liner thicknesses maximizing tibial rotation were 11mm in 12 TKAs, 12mm in four TKAs, and 13mm in two TKAs. Mean ± SD maximal tibial rotation was 17 ± 4.1°, which was 4° more than with a 1mm thinner (13 ± 5°) and 1mm thicker (13 ± 5.3°) insert (pɘ.001).
Conclusions: Surgeons performing KA TKA through a medial parapatellar approach can utilize the insert goniometer to select the insert thickness that maximizes tibial rotation. Maximizing tibial rotation with a medial ball-in-socket and lateral flat insert conformity restores physiologic knee kinematics and dynamically stabilizes the patella.
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Patient Satisfaction and Outcomes Utilizing a Portable Medical Device with Adaptive Telemedicine Technology for Rehabilitation Following Total Knee Arthroplasty
Zuhdi E. Abdo, MD, Assistant Professor, Rutgers New Jersey Medical School, Newark, New Jersey, Sean Bonanni, MD, Kansas City Orthopedic Alliance, Leawood, Kansas, Maxwell E. Weinberg, MD, Northwell Health, Garden City, New York, Giles R. Scuderi, MD, Professor, Zucker School of Medicine at Hofstra, Northwell Health, Garden City, New York
1850
Introduction: A portable medical rehabilitation device with adaptive telemedicine technology provides an adjunct therapy following total knee arthroplasty (TKA). The physician-monitored internet-based interface allows for physician-directed or free use of the portable medical rehabilitation device by the patient. The purpose of this study was to characterize patients’ satisfaction with its use, as well as its impact on perioperative range of motion (ROM).
Materials and Methods: After institutional review board (IRB) approval, patients who used the portable rehab device postoperatively completed a 12-question survey that assessed use and satisfaction metrics at their six-week postoperative visit. Range of motion (ROM) at their six-week postoperative visit was analyzed against their survey responses. A total of 101 patients (42 men, 58 women, one preferred not to answer; 101 knees) were available for analysis, with a mean patient age of 68 years (range 48–84 years).
Results: Overall satisfaction was 93%, with 14.9% noted “helpful,” 45.5% “strongly helpful,” and 32.7% “very strongly helpful.” Insurance covered the cost in 72%, while 23% paid for their device out of pocket with minimal impact, and 5% felt the out-of-pocket cost to be not worthy of the benefit. Nearly all (96%) of the patients stated they would recommend the device. Patients reported using their portable medical rehabilitation device for approximately two to three weeks (39.6%), two to three times per day (65.3%), and 11 to 15 minutes per session (69.3%). Older patients had lower usage than younger patients (p<0.001), and men trended toward higher usage than women (p=0.055). Mean six-week postoperative knee ROM was a 0–111° arc of motion. Change in ROM was not found to correlate with duration of use (p=0.385).
Conclusion: The portable medical device is an option for rehabilitation after TKA with high patient satisfaction and low-cost burden, while achieving an appropriate arc of motion by six weeks following TKA. Further comparative investigations will be needed to determine the optimal duration of use following TKA.
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