Book XXI - PrePrint Issue


STI XXI - Preview - Orthopaedic Surgery

 

Evaluation of Primary Total Knee Arthroplasty Incision Closure with the Use of Continuous Bidirectional Barbed Suture
Scott Stephens, MD, Resident Physician, Mount Carmel Medical Center, Columbus, Ohio, Joel Politi, MD, Department of Orthopedic Surgery Teaching Staff, Mount Carmel Medical Center, Columbus, Ohio, Ben C. Taylor, MD, Trauma Fellow, Grant Medical Center, Columbus, Ohio

 

  • Abstract
    • The purpose of this study is to determine whether operative time for primary total knee arthroplasty can be decreased with the use of a continuous barbed suture. Five hundred patients were retrospectively reviewed and divided into groups based on whether incision closure utilized a continuous barbed suture or an interrupted biodegradable suture. We identified additional variables to determine their relationship to operative time, including body mass index, age, gender, and side of replacement. The results demonstrated a decrease in operative time by an average of 4 minutes (P < .001) with the use of barbed suture, without an associated increase in complications. Statistically significant relationships were found between operative time and variables such as body mass index, age, and gender, but not side of replacement.

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Percutaneous Posterolateral Transforaminal Endoscopic Discectomy: Clinical Outcome, Complications, and Learning Curve Evaluation   

Shay Tenenbaum, MD,  Resident, Department of Orthopedic Surgery Sheba Medical Center, Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Harel Arzi, MD, Spine Fellow University of Kansas Medical Center Department of Neurosurgery Kansas City, Kansas  Amir Herman, MD,  Resident, Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Alon Friedlander, MD, Senior Surgeon, Spine Deformity Unit Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Moshe Levinkopf, MD, Senior Surgeon, Spine Deformity Unit  Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel  Paul M. Arnold, MD, Professor of Neurosurgery Department of Neurosurgery University of Kansas Medical Center Kansas City, Kansas  Israel Caspi, MD, Senior Surgeon, Spine Deformity Unit Department of Orthopedic Surgery Sheba Medical Center Tel-Hashomer, Israel The Sackler School of Medicine Tel Aviv University, Israel

 

  • Abstract
    • Ongoing technological development combined with better understanding of endoscopic anatomy has made posterolateral endoscopic discectomy an appealing surgical option for the management of herniated lumbar disc. We evaluated clinical outcomes, complication rates, and surgical learning curve with the percutaneous posterolateral transforaminal endoscopic discectomy technique (PPTED). PPTED was performed on 150 patients from 2004 to 2008. And 124 patients were available for follow-up. Data regarding pain, postoperative complications, neurological status, operation time, and subjective patient satisfaction were recorded. A satisfactory clinical outcome as reflected in the VAS (mean 3.6) and ODI improvement (mean 21%) scores was reported; 20.9% of the patients required additional surgery. Learning curve assessment showed a significant difference (p = 0.043) for fewer revision surgeries as surgeons became more experienced. Patients who had endoscopic discectomy as a primary surgery achieved significantly lower VAS (p = 0.04) and ODI improvement (p = 0.004) scores compared with patients having transforaminal endoscopic discectomy as revision surgery. The complication rate was 1.6%, including one case of post-surgery hypoesthesia and one deep wound infection. The percutaneous posterolateral transforaminal endoscopic discectomy technique has a satisfactory clinical outcome with a low complication rate. Results for endoscopic surgery for revision or recurrent disc herniation are comparable to those of open revision surgery; the steep learning curve can be overcome with training and suitable patient selection.

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Neuromuscular Adaptations in Gluteus Medius Activity Following Resurfacing and Total Hip Arthroplasty   
Manoshi Bhowmik-Stoker, PhD, Motion Analysis Lab Manager, BSHRI-CORE Orthopedic Labs, Banner Sun Health Research Institute, Sun City, Arizona,  Christopher A. Buneo, PhD, Assistant Professor, School of Biological & Health Systems Engineering, Arizona State University, Tempe, Arizona,  Michael Wade Shrader, MD, Orthopaedic Surgeon and Director of Research, Department of Orthopaedic Surgery, Phoenix Children's Hospital, Phoenix, Arizona,  Marc C. Jacofsky, PhD, Vice President of Research and Development, The Core Institute, Phoenix, Arizona

 

  • Abstract
    • In middle-aged patients, the choice between resurfacing and total hip arthroplasty may be difficult given recent studies showing differences in functional outcomes. Success of clinical outcomes, defined by a greater range of motion and reduced pain following surgery, are dependent on a return in function of incised muscle groups. To identify neuromuscular recovery following hip arthroplasty, hip abductor activity was assessed throughout the first year of recovery. Analysis focused on characterization of the temporal activity of the gluteus medius during activities of daily living. Adaptation in muscle firing and biomechanical outcomes was revealed in both groups, though more pronounced in the THA cohort with increasingly difficult activities. Differences between groups should be considered by clinicians when considering the best treatment options for their patients.

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Total Joint Arthroplasty in Patients with Obstructive Sleep Apnea: Strategies for Reduction of Perioperative Complications   James Cashman, MD, Arthroplasty Fellow,  Orhan Bican, MD, Research Fellow,  Ravi Patel, BS, Research Fellow, Christina Jacovides, BS, Research Fellow,  Chelsea Dalsey, BS, Research Fellow,  Javad Parvizi, MD, FRCS, Professor Of Orthopedics,  Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

 

  • Abstract
    • Obstructive sleep apnea (OSA) has been associated with increased risk for medical complications following total joint arthroplasty. Our institution employs postoperative precautions for OSA patients in an effort to minimize the impact of postoperative complications in this group. We performed this study to assess the effect of careful monitoring on postoperative complication rates in OSA patients. We identified patients with a clinically suspected or objective diagnosis of OSA who received total joint arthroplasty between January 1998 and January 2008. 1016 cases in 792 OSA patients were matched to 1016 cases in 993 control patients to compare complication rates. There were no differences between OSA and control patients in cardiovascular and respiratory complications following TJA. Patients with OSA experienced increased rates of postoperative acute renal failure when compared with controls (p = 0.02) and experienced mild desaturations (Hb O2 < 92%) (p = 0.002), but not severe desaturations (Hb O2 < 88%) (p = 0.2). We conclude that our postoperative monitoring protocols are successful in reducing postoperative complications most commonly associated with OSA. We were interested to note the increased risk for OSA patients to develop postoperative acute renal failure and believe that future study is warranted to explore the link between OSA and renal failure.

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A Prospective, Randomized Study of Component Position in Two-Incision MIS Total Hip Arthroplasty: A Preliminary Study   
R. Michael Meneghini, MD, Director of Joint Replacement, IU Health Saxony Hospital, Indiana University Health Physicians, Assistant Professor of Clinical Orthopaedic Surgery, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, Shelly A. Smits, RN , Indiana University Health Physicians, Indianapolis, Indiana

 

  • Abstract
    • Controversy exists regarding the ability to position the implants reliably in minimally invasive surgery (MIS) total hip arthroplasty (THA). This study compared the ability to accurately position components in the MIS two-incision versus single-incision approaches. Twenty-four patients were randomized to THA through one of three approaches, including the two-incision approach. Component position was measured with computed tomography. The mean deviation from the target acetabular anteversion was 14.8 degrees in the two-incision MIS group versus 6.4 degrees in the other two approaches (p = 0.006). A mean of 9.8 degrees deviation from the target femoral anteversion in the two-incision MIS approach group was observed compared with 5.3 degrees in the single-incision groups (p = 0.05). These results suggest there is a decreased ability to accurately position the components in the two-incision approach.

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A Comparison Study of Two  Cruciate-Retaining Total Knee Designs:  A Preliminary Report   
Frank R. Kolisek, MD, Surgeon, OrthoIndy, Indianapolis, Indiana,  Michael A. Mont MD, Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,  Christopher R. Costa MD, Orthopaedic Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland,  Charles E. Jaggard, RA, Research Coordinator, OrthoIndy, Indianapolis, Indiana,    Aaron J. Johnson MD, Orthopaedic Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland

 

  • Abstract
    • Cruciate-retaining total knee arthroplasties have had high success rates. The purpose of this study was to compare a newer cruciate-retaining design to a previously used implant to determine if there were any changes in clinical or functional outcome. A total of 461 patients (553 knees) were identified who had total knee arthroplasty with this newer design. At latest 2-year follow-up, the mean range of motion was 121 degrees (range 105 to 140 degrees), the mean Knee Society pain score was 91 points (range, 57 to 100 points) and the functional score was 76 points (45 to 100 points). The comparison group of 211 patients (225 knees) had a mean range of motion of 119 degrees at 2 years (range, 90 to 142 degrees) with Knee Society pain and functional scores of 95 and 85 points, respectively (ranges 57 to 100, and 0 to 100, respectively). The use of the newer cruciate-retaining total knee arthroplasty showed comparable results to the previously used design at short-term follow-up. The cruciate-retaining design used in this study had no early failures, though further study is needed to make assessments regarding longer-term functional results and outcomes.

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Modern Dual Mobility Cups for Total Hip Arthroplasty   

Nitin Goyal, MD. Adult Reconstruction Fellow. Thomas Jefferson University Hospital & The Rothman Institute. Philadelphia, Pennsylvania.  Mohan S. Tripathi. Medical Student. Jefferson Medical College. Thomas Jefferson University. Philadelphia, Pennsylvania.  Javad Parvizi, MD. Professor of Orthopaedic Surgery. Thomas Jefferson University Hospital & The Rothman Institute Philadelphia, Pennsylvania

 

  • Abstract
    • Dislocation after total hip arthroplasty remains a primary concern among orthopaedic surgeons. Endeavors to decrease the incidence of dislocation, while maintaining limb function and mobility, have been painstakingly undertaken. Since their advent in the 1970s, dual mobility cups have proven again and again to be effective in reducing dislocation following total hip arthroplasty. The dual mobility cup enables the surgeon to treat patients with an increased risk for dislocation, while maintaining hip stability, favorable wear properties, and an acceptable rate of dislocation. Disadvantages are related to the potential increased wear and surgeon error. With advances in engineering and design, dual mobility cups have proven useful in providing lower dislocation rates for several pathological conditions. As a result, dual mobility cups have moved into the forefront of total hip arthroplasty.

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Full-endoscopic Operations of the Spine in Disk Herniations and Spinal Stenosis   

Sebastian Ruetten, MD, Head of the Department of Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology, St. Anna Hospital Herne, Herne, Germany

 

  • Abstract
    • Degenerative constrictions of the spinal canal with compression of neural elements arise as a result of bony, disk, capsular, or ligament structures. The most frequent causes are disk herniations and spinal stenoses. The lumbar and cervical spine is the most prominent cause. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical, microscopically assisted decompression is regarded as the standard procedure for disk herniation and spinal stenosis in the lumbar region, while in the cervical spine microsurgical, microscopically assisted anterior decompression and fusion are standard. Both procedures demonstrate good clinical results but present problems associated with the operation. Decompressions in the area of the spine must be carried out under continuous visualization and must entail the possibility of adequate bone resection. Taking this into account, completely new endoscopes and instrument sets were developed for full-endoscopic operations in tandem with the development of the lateral transforaminal and interlaminar approaches for the lumbar spine and the posterior and contralateral anterior approaches for the cervical spine. The possibilities and results of comparable, established standard procedures were used as a benchmark in the course of clinical validation. The development of surgically created approaches and the new rod lens endoscopes combined with appropriate instrument sets have laid the technical foundations for full-endoscopic operation in the lumbar spine on all primary and recurrent disk herniations inside and outside the spinal canal and on spinal stenoses. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the relevant approaches depends on anatomical and pathological inclusion and exclusion criteria. The clinical results of standard procedures are achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of EBM criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the defined indications with reduced traumatization, improved visibility conditions, and positive cost benefits. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

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Excellent Clinical Outcomes in Total Knee Arthroplasty Performed Without a Tourniquet  

D. Alex Stroh, BS, Medical Student, MSIV, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Aaron J. Johnson, MD, Orthopaedic Research Fellow, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Director, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Peter M. Bonutti, MD, Director, Bonutti Clinic, Effingham, Illinois

 

  • Abstract
    • Although tourniquet use is the standard protocol for total knee arthroplasties it may lead to postoperative complications including thigh pain, compressive soft-tissue problems, and thromboembolic events. The purpose of this study was to explore the perioperative and clinical outcomes of total knee arthroplasty performed without a tourniquet. Thirty consecutive total knee arthroplasties were performed in 30 patients without a tourniquet and compared with 30 procedures (30 matched patients) performed with a tourniquet. Tourniquet patients had statistically lower mean intraoperative blood loss, total blood loss, and change in hematocrit, but these did not have any clinical impact or change the transfusion rate between the groups. At a mean follow-up of 3 years, both groups achieved excellent mean Knee Society scores with similar improvements between groups. There were no complications or radiographic abnormalities in either group. Total knee arthroplasty performed with or without a tourniquet yields similar intraoperative surgical and postoperative clinical outcomes.

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