Surgical Technology International
32nd Edition
Contains 45 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
368 pages
May 2018 - ISSN:1090-3941
1 year Institutional Subscription
both electronic and print versions
Early Experience with a Short, Tapered Titanium Porous Plasma Sprayed Stem with Updated Design
Adolph V. Lombardi Jr., MD, FACS, President, Joint Implant Surgeons, Inc., New Albany, Ohio, Clinical Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Antonio G. Manocchio, Jr., DO, Fellow, Joint Implant Surgeons, Inc., New Albany, Ohio, Associate, Orthopedic Surgeons of Southwest Ohio, Dayton, Ohio, Keith R. Berend, MD, Vice President, Joint Implant Surgeons, Inc., New Albany, Ohio, Chief Executive Officer and President, White Fence Surgical Suites, New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Michael J. Morris, MD, Partner, Joint Implant Surgeons, Inc., New Albany, Ohio, Attending Surgeon, Mount Carmel Health System, Columbus, Ohio, Joanne B. Adams, BFA, CMI, Research Director and Medical Illustrator, Joint Implant Surgeons, Inc., New Albany, Ohio
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Introduction: Short stem femoral components in primary total hip arthroplasty (THA) have increased in popularity since the advent of minimally invasive surgical techniques. The concept of a short stem is particularly compatible with tapered designs where the goal is to offload forces proximally in the femur. The purpose of this retrospective review was to review our early experience with a short, tapered titanium femoral component with updated design features.br /> Materials and Methods: Beginning in November 2011 through February 2012, 92 consented patients (93 hips), at a single center, were treated with primary cementless THA using a short stem, tapered femoral component (Taperloc® Complete Microplasty; Zimmer Biomet, Warsaw, Indiana) and were available for review with a minimum two-year follow-up. Mean patient age at surgery was 63.2 years and body mass index (BMI) was 30.8 kg/m2. Mean stem length used was 110.3mm (range, 95–125). br /> Results: Mean follow-up was 4.5 years (2–6). Harris hip scores improved from 52.5 preoperatively to 84.7 at most recent. One stem was revised the same day for periprosthetic fracture. One patient with early infection was treated with single-stage exchange followed by recurrence that was treated successfully with two-stage exchange. A non-healing wound in one patient was treated with incision and debridement. Radiographic assessment demonstrated no evidence of loosening, osteolysis, distal hypertrophy, or pedestal formation in any hip, and all components appeared well fixed and in appropriate alignment. br /> Conclusion: In this series of patients treated with primary THA using a short, tapered titanium porous plasma-sprayed femoral component with updated design features, good results were achieved with a low incidence of complications and revision. No aseptic loosening or osteolysis has occurred. Radiographic assessment was excellent for all patients.
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Articulating Spacers as a Modified One-Stage Revision Total Knee Arthroplasty: A Preliminary Analysis
Ahmed Siddiqi, DO, Resident, Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Nicole E. George, DO, Research Fellow, Bartlomiej W. Szczech, MD, Clinical Fellow, Jennifer I. Etcheson, MD, MS, Research Fellow, Chukwuweike U. Gwam, MD, Research Fellow, Alexander T. Caughran, MD, Clinical Fellow, Ronald E. Delanois, MD, Director, James Nace, DO, MPT, Fellowship Director/Academic Director, Hip, Knee, and Shoulder Surgery, Rubin Institute Adult Hip and Knee Reconstruction Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland, Peter B. White, BA, Research Assistant, Department of Orthopedic Surgery, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, John V. Thompson, DO, Resident, Department of Orthopaedic Surgery, Wellspan York Hospital, York, Pennsylvania
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Introduction: Periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) is a challenging complication for surgeons and patients alike. Although two-stage revision arthroplasty remains the gold standard PJI management in the United States, one-stage revision has had success in many parts of Europe. The aim of this study was to retrospectively review: 1) ultimate treatment success; 2) necessary antibiotic duration; 3) change in knee range of motion (ROM); and 4) final Knee Society Scores (KSS) in a case series of patients managed with retention of articulating antibiotic spacers following PJI.
Materials and Methods: A retrospective review was performed on all patients treated for chronic PJI after primary TKA with retention of articulating antibiotic spacers at a minimum of one-year follow-up. Descriptive analysis was utilized to evaluate demographic characteristics, discharge destination, follow-up and antibiotic durations, Knee Society Score (KSS), and rates of treatment failure. Paired-Samples t-Tests were utilized to evaluate mean changes in flexion and extension between the preoperative and postoperative time periods.
Results: Our final cohort included 29 patients who were managed with articulating spacer retention at a mean follow-up of 16.8 (range, 12.0 to 23.1) months, with 21 patients (72.4%) medically unfit for multiple surgeons and eight patients (27.6%) satisfied with their function. Mean age was 61.3 (range, 41 to 85) years and mean Charlson Comorbidity Index (CCI) was 6.1 (mean, 0 to 12). The predominant infecting organism was Methicillin-Resistant Staphylococcus aureus (MRSA), which was involved in eight patients (27.6%). There was a significant increase in postoperative knee flexion (+14.7°; p=0.001) and no decrease in postoperative knee extension (+2.3°; p=0.361). Treatment success in our cohort was 79.3% (23 patients), with four patients (13.8%) having chronic wound drainage and two patients (6.9%) requiring multiple spacer exchanges. Sixteen patients (55.2%) were able to complete their antibiotic regimen, with the remaining patients unable to discontinue their antibiotics by latest clinic follow-up.
Discussion: One-stage exchange arthroplasty offers the advantage of a single procedure with analogous failure rates compared to two-stage exchange, decreases hospitalization, and improves cost-effectiveness, which is paramount in today’s healthcare environment. To our knowledge, this is the first study in the United States to evaluate outcome scores, function, and success rate of a modified one-stage revision TKA technique. Although we are unable to make definitive conclusions based on the small sample size, the outcomes in this study are encouraging.
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Cost Analysis of All-Polyethylene Compared to Metal-Backed Implants in Total Knee Arthroplasty
Karim Sabeh, MD, Orthopaedic Surgery Chief Resident, Milad Alam, MD, Orthopaedic Surgery Resident, Samuel Rosas, MD, Orthopaedic Surgery Resident, Shahrose Hussain, BS, Medical Student, Michaela Schneiderbauer, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery and Rehabilitation, The University of Miami Miller School of Medicine, Miami, Florida
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Introduction: The growing trends of total knee arthroplasty (TKA) foreshadow an inevitable increase in the financial burden on healthcare expenditure estimated to almost nine billion dollars annually. This study aims to demonstrate the potential savings when using all-polyethylene (AP) compared to metal-backed (MB) tibial components and describes the cost variability amongst three major commercially available implants.
Materials and Methods: The cost of AP versus MB implants was analyzed using a large nationwide database, Emergency Care Research Institute (ECRI). Cost of femoral components and patellar buttons were excluded. The three manufacturers included in the study were DePuy, Smith&Nephew, and Stryker (Zimmer data was not available for analysis).
Results: Our results show that AP components were significantly less costly in comparison to other manufacturers, and the average AP price was $1,009. The average MB (baseplate plus liner) price was $2,054 (p=0.01). Analysis of variance (ANOVA) of the means of the AP components showed no significant difference in prices among the three studied manufacturers (p=0.946).
Discussion: Our results demonstrate that, regardless of the manufacturing company, AP tibial components are significantly cheaper than their MB counterparts. A literature review revealed that, when indicated, AP implants are not inferior to MB in terms of survivorship or outcome. The average savings was more than $1,000 per TKA when multiplied even by a small portion of the large volume of TKAs completed annually. This can translate into millions of dollars in savings in healthcare expenditures. With the impending legislation of the bundled-payment initiative, orthopaedic surgeons should be aware of less costly implant options that can positively impact outcomes and/or quality of care.
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Complex Fibular Head Avulsion Fracture: Surgical Management of a Case
Vittorio Mattugini, MD, Specialist in Orthopedics and Traumatology, Carmine Citarelli, MD, Resident in Orthopedics and Traumatology, Fabio Cosseddu, MD, Resident in Orthopedics and Traumatology, Marco Ghilardi, MD, Specialist in Orthopedics and Traumatology, Guido Luppichini, MD, Specialist in Orthopedics and Traumatology, Francesco Casella, MD, Specialist in Orthopedics and Traumatology, Giulio Agostini, MD, Resident in Orthopedics and Traumatology, Federico Sacchetti, MD, Resident in Orthopedics and Traumatology, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, Department of Orthopedic and Traumatology, University of Pisa, Pisa, Italy
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Fibular head avulsion fractures are rare injuries determined by traction of the fibular attachment of the lateral collateral ligament (LCL). Surgical treatment is often recommended with different techniques such as tension band fixation or lag screws stabilization. In this article, we describe a fixation technique of fibular head fractures obtained through the use of anchors. A 45-year-old athletic patient came to our attention in our traumatologic service after a motorcycle accident. He reported a complex injury of the posterolateral corner with an avulsion fracture of the left fibular head. We performed a clinical evaluation at the final follow-up visit (six months). We demonstrated that the use of suture anchors may be an effective technique of fixation in avulsion fracture of the fibular head associated with combined posterolateral corner injuries.
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Perioperative Outcomes and Short-Term Complications Following Total Knee Arthroplasty in Chronically Immunosuppressed Patients
Gannon L. Curtis, MD, Research Fellow, Morad Chughtai, MD, Resident, PGY-1, Anton Khlopas, MD, Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Carlos A. Higuera, MD, Vice Chair for Quality and Patient Safety, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Wael K. Barsoum, MD, President, Department of Orthopaedic Surgery, Cleveland Clinic, Weston, Florida, Jared M. Newman, MD, Research Fellow, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
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Background: Although there are studies regarding immunosuppressed patients undergoing total knee arthroplasty (TKA) for inflammatory arthritis or osteonecrosis, there is a paucity of studies evaluating immunosuppressed patients undergoing TKA for diagnoses other than these.
Materials and Methods: We identified all patients undergoing primary TKA for osteoarthritis from 2008–2014 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Overall, 111,624 patients were included. The immunosuppressed group consisted of 3,466 patients, and the control group included 108,158. Outcomes measured included operative time, lengths-of-stay, discharge destination, and 30-day complication rates. Univariate analysis was used to compare the outcomes. Multivariate regression analysis was then applied to determine if immunosuppression was an independent risk factor for differences in outcomes.
Results: Immunosuppressant use did not change operative time, lengths-of-stay, or discharge disposition. Immunosuppressed patients were at higher risks of developing the following surgical and medical complications: organ/space surgical site infection (SSI), wound dehiscence, deep venous thrombosis (DVT), pneumonia, urinary tract infection (UTI), and systemic sepsis. Return to the operating room and 30-day readmission were also significantly higher in the immunosuppressed group.
Conclusions: Patients taking chronic immunosuppressants and undergoing TKA for osteoarthritis are at higher risk of specific surgical and medical complications. These complications include organ/space SSI, wound dehiscence, DVT, pneumonia, UTI, and systemic sepsis. In addition, these patients were at increased odds of returning to the operating room and being readmitted.
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Robotic-Assisted and Computer-Navigated Unicompartmental Knee Arthroplasties: A Systematic Review
Qais Naziri, MD, MBA, Orthopaedic Surgery Resident, Daniel P. Murray, BS, Medical Student, Roby Abraham, MD, Orthopaedic Surgery Resident, Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York, Patrick J. Mixa, MD, Orthopaedic Surgery Resident, Bashir A. Zikria, MD, MSc, Associate Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, Akhilesh Sastry, MD, Orthopaedic Surgeon, Department of Orthopaedic Surgery, Portsmouth Regional Hospital, Portsmouth, New Hampshire, Preetesh D. Patel, MD, Director of the Adult Joint Reconstruction Fellowship, Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Introduction: Unicompartmental knee arthroplasty (UKA) effectively improves pain and function associated with isolated compartmental knee arthritis. The developments of computer-navigated and robotic-assisted UKA are among the most significant changes that have improved patient outcomes. This study aimed to systematically review the literature to identify differences between computer-navigated and robotic-assisted UKAs.
Materials and Methods: Twenty total articles were identified. Data pertaining to demographics, outcomes, and complications/failures were extracted from each study. Reoperation/revision rates, indications for reoperation/revision, type of procedure, and number of patients who underwent conversion to TKA (when available) were recorded.
Results: Nine studies reported 451 computer-navigated medial UKAs, with 19 (3.9%) reportedly requiring reoperation: primary revision (n=8; 42.1%), conversion to TKA (n=6), and manipulation under anesthesia (n=5). Eleven studies reported 2,311 robotic-assisted UKAs (74 lateral UKAs), with 106 (5.0%) requiring reoperation: conversion to TKA (n=46; 43.4%), primary revision (n=43), reoperations without component-removal (n=15), subchondroplasty, and partial meniscectomy/synovectomy (both n=1). Reoperation rate discrepancy between computer-navigated and robotic-assisted UKA was not statistically significant (p=0.495); age and BMI differed between both groups (p<0.0001).
Discussion: This study represents the first known comparison of revision rates of computer-navigated and robotic-assisted UKA, suggesting that these methods can benefit orthopaedic surgeons, especially those new to UKA or in a low-volume practice.
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Decreased Time to Return to Work Using Robotic-Assisted Unicompartmental Knee Arthroplasty Compared to Conventional Techniques
Alexander H. Jinnah, MD, Physician Scientist/Resident, Marco A. Augart, MD, Research Fellow, Daniel L. Lara, MD, Research Fellow, Gary G. Poehling, MD, Professor, Johannes F. Plate, MD, PhD, Resident, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, Riyaz H. Jinnah, MD, FRCS, Professor, Department of Orthopaedic Surgery, Southeastern Regional Medical Center, Lumberton, North Carolina, Chukwuweike U. Gwam, MD, Research Fellow, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Unicompartmental knee arthroplasty (UKA) is a commonly used procedure for patients suffering from debilitating unicompartmental knee arthritis. For UKA recipients, robotic-assisted surgery has served as an aid in improving surgical accuracy and precision. While studies exist detailing outcomes of robotic UKA, to our knowledge, there are no studies assessing time to return to work using robotic-assisted UKA. Thus, the purpose of this study was to prospectively assess the time to return to work and to achieve the level of work activity following robotic-assisted UKA to create recommendations for patients preoperatively. We hypothesized that the return to work time would be shorter for robotic-assisted UKAs compared with TKAs and manual UKAs, due to more accurate ligament balancing and precise implementation of the operative plan.
Materials and Methods: Thirty consecutive patients scheduled to undergo a robotic-assisted UKA at an academic teaching hospital were prospectively enrolled in the study. Inclusion criteria included employment at the time of surgery, with the intent on returning to the same occupation following surgery and having end-stage knee degenerative joint disease (DJD) limited to the medial compartment. Patients were contacted via email, letter, or phone at two, four, six, and 12 weeks following surgery until they returned to work. The Baecke physical activity questionnaire (BQ) was administered to assess patients’ level of activity at work pre- and postoperatively. Statistical analysis was performed using SAS Enterprise Guide (SAS Institute Inc., Cary, North Carolina) and Excel® (Microsoft Corporation, Redmond, Washington). Descriptive statistics were calculated to assess the demographics of the patient population. Boxplots were generated using an Excel® spreadsheet to visualize the BQ scores and a two-tailed t-test was used to assess for differences between pre- and postoperative scores with alpha 0.05.
Results: The mean time to return to work was 6.4 weeks (SD=3.4, range 2–12 weeks), with a median time of six weeks. There was no difference seen in the mean pre- and postoperative BQ scores (2.70 vs. 2.69, respectively; p=0.87).
Conclusion: The findings of the current study suggest that most patients can return to work six weeks following robotic-assisted UKA which appears to be shorter than conventional UKA and TKA. Future level I studies are needed to verify our study findings.
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Hip Osteoarthritis Patients Demonstrated Marked Dynamic Changes and Variability in Pelvic Tilt, Obliquity, And Rotation: A Comparative, Gait-Analysis Study
Assem A. Sultan, MD, Clinical Research Fellow, William A. Cantrell, BS, Medical Student, Anton Khlopas, MD, Research Fellow, Inyang Udo-Inyang, Jr., MD, PGY-2 Orthopaedic Surgery Resident, Morad Chughtai, MD, PGY-1 Orthopaedic Surgery Resident, Nipun Sodhi, BA, Research Fellow, Suela Lamaj, BS, Research Volunteer, Nicolas S. Piuzzi, MD, Orthopedic Regenerative Medicine and Cellular Therapy Clinical Scholar, Michael A. Mont, MD, Chairman, PGY-2 Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Roland Starr, MS, Physiotherapist, Anil Bhave, PT, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Changes in pelvic position has been shown to affect acetabular coverage of the femoral head in total hip arthroplasty (THA) and may contribute to complications such as impingement, dislocation, or early wear. Understanding the kinematic changes of these positions during functional activities may help surgeons reach a consensus regarding stable hip mechanics and ideal implant positioning in THA. Therefore, in this study, we aimed to evaluate the following in patients who had unilateral hip OA: 1) dynamic changes; and 2) variability; in the following pelvic position parameters: A) tilt; B) obliquity; and C) rotation standing position to walking. This same data was also collected from a control cohort of normal subjects with non-arthritic hip joints. Data from both cohorts were then compared.
Materials and Methods: This study analyzed 50 patients who had unilateral osteoarthritis of the hip. There were 27 men and 23 women who had a mean age of 59 years, a mean height of 173 cm (range, 152 to 200 cm), a mean weight of 84 kg (range, 31.5 to 125 kg), and a mean body mass index (BMI) of 28 kg/m2 [range, 13 to 43 kg/m2). In addition, a cohort of 19 healthy subjects with matching demographics (11 men and 9 women, mean age; 64, mean height; 168 cm, mean weight; 88 kg, mean BMI; 30 kg/m2) served as a control group. Joint marker sets were used for analysis and specific markers were used to assess pelvic position of the participants. In each cohort, mean pelvic tilt, obliquity, and rotation values in standing position, as well as mean minimum and maximum values in walking position were collected and compared. Dynamic change from standing to walking was calculated in both cohorts and then compared. Variability was demonstrated by comparing a graphic representation of individual values from both cohorts.
Results: In hip OA patients, wide dynamic changes were demonstrated in pelvic tilt, obliquity, and rotation when going from a standing to a walking position (pelvic tilt; mean standing +8°, [range, -5° to +32°], walking range -13.5° to +33°, obliquity; mean standing +0.4°, [range, -8° to 7°], walking range -14° to +10°, rotation; mean standing -1.5° [range, -16 to +10°], and walking range -28° to +13°). In the non-arthritic cohort, narrower ranges of dynamic changes were recorded (pelvic tilt; mean standing +7°, [range, +4.35° to +9.81°], walking range +4.35° to +9.81°, obliquity; mean standing +0.66°, [range, -0.35° to 1.67°], walking range [-2.8° to 5.1°], rotation; standing mean +0.5° [range, -1.16° to +2.16°], and walking range [-6.8° to +5.1°]). When both cohorts were compared, the hip OA cohort had a three- to four-folds increase in dynamic change relative to the non-arthritic group, and in pelvic tilt, obliquity, and rotation (pelvic tilt; 38.5° vs. 9.3°, obliquity; 23.6° vs. 7.24°, rotation; 39.5° vs. 11.4). In addition, marked variability in pelvic position was also demonstrated when walking ranges of all three parameters for hip OA patients were compared to the non-arthritic subjects.
Conclusion: This study utilized a novel and innovative approach to analyze the dynamic changes and variability in pelvic position parameters in patients with hip OA in comparison to non-arthritic matching subjects. Hip OA patients showed marked changes in pelvic tilt, obliquity, and rotation when going from standing to walking. Non-arthritic subjects exhibited much less noticeable changes in all three parameters. When dynamic changes in both cohorts were compared, hip OA patients had a three- to four-folds increase relative to the non-arthritic group with marked variability in walking ranges. These findings may have implications on the acetabular spatial orientation and highlight the need for individual planning when undertaking THA to account for the dynamic changes in pelvic position parameters during functional activities.
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Filling Open Screw Holes in the Area of Metaphyseal Comminution Does Not Affect Fatigue Life of the Synthes Variable Angle Distal Femoral Locking Plate in the AO/OTA 33-A3 Fracture Model
Luis Grau, MD, Chief Resident, Kevin Collon, BS, Medical Student, Ali Alhandi, MD, Resident, Fernando Vilella, MD, Assistant Professor, Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida, David Kaimrajh, MS, Engineering Department, Loren Latta, PhD, Chief Engineer, Engineering Department, Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, Miami, Florida, Maria Varon, BS, Graduate Student, Department of Biomedical Sciences, Barry University, Miami Shores, Florida
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Introduction: The aim of this study is to evaluate the biomechanical effect of filling locking variable angle (VA) screw holes at the area of metaphyseal fracture comminution in a Sawbones® (Sawbones USA, Vashon, Washington) model (AO/OTA 33A-3 fracture) using a Synthes VA locking compression plate (LCP) (Depuy Synthes, Warsaw, Indiana).
Materials and Methods: Seven Sawbones® femur models had a Synthes VA-LCP placed as indicated by the manufacturers technique. A 4cm osteotomy was then created to simulate an AO/OTA 33-A3 femoral fracture pattern with metaphyseal comminution. The control group consisted of four constructs in which the open screw holes at the area of comminution were left unfilled; the experimental group consisted of three constructs in which the VA screw holes were filled with locking screws. One of the control constructs was statically loaded to failure at a rate of 5mm/min. A value equal to 75% of the ultimate load to failure was used as the loading force for fatigue testing of 250,000 cycles at 3Hz. Cycles to failure was recorded for each construct and averages were compared between groups.
Results: The average number of cycles to failure in the control and experimental groups were 37524±8187 and 43304±23835, respectively (p=0.72). No significant difference was observed with respect to cycles to failure or mechanism of failure between groups. In all constructs in both the control and experimental groups, plate failure reproducibly occurred with cracks through the variable angle holes in the area of bridged comminution.
Conclusions: The Synthes VA-LCP in a simulated AO/OTA 33-A3 comminuted metaphyseal femoral fracture fails in a reproducible manner at the area of comminution through the “honeycomb” VA screw holes. Filling open VA screw holes at the site of comminution with locking screws does not increase fatigue life of the Synthes VA-LCP in a simulated AO/OTA 33-A3 distal femoral fracture. Further studies are necessary to determine whether use of this particular plate is contraindicated when bridging distal femoral fractures with metaphyseal comminution.
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The Role of Virtual Rehabilitation in Total Knee and Hip Arthroplasty
Morad Chughtai, MD, Resident, PGY-1, Assem A. Sultan, MD, Clinical Research Fellow, Anton Khlopas, MD, Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Jared M. Newman, MD, Research Coordinator, Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, Sergio M. Navarro, BS, Medical Student, Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, Anil Bhave, PT, Director of Physical Therapy, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Virtual rehabilitation therapies have been developed to focus on improving care for those suffering from various musculoskeletal disorders. There has been evidence suggesting that real-time virtual rehabilitation may be equivalent to conventional methods for adherence, improvement of function, and relief of pain seen in these conditions. This study specifically evaluated the use of a virtual physical therapy/rehabilitation platform for use during the postoperative period after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The use of this technology has the potential benefits that allow for patient adherence, cost reductions, and coordination of care.
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Postoperative Pain and Analgesia: Is There a Genetic Basis to the Opioid Crisis?
Randa K. Elmallah, MD, PGY-2 Orthopaedic Resident, University of Mississippi, Department of Orthopaedic Surgery, Jackson, Mississippi, Prem N. Ramkumar, MD, MBA, PGY-2 Orthopaedic Resident, Anton Khlopas, MD, Clinical Research Fellow, Rathika R. Ramkumar, MD, Urology Resident, Morad Chughtai, MD, PGY-1 Orthopaedic Resident, Nipun Sodhi, BA, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, Michael A. Mont, MD, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
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Background: Multiple factors have been implicated in determining why certain patients have increased postoperative pain, with the potential to develop chronic pain. The purpose of this study was to: 1) identify and describe genes that affect postoperative pain perception and control; 2) address modifiable risk factors that result in epigenetic altered responses to pain; and 3) characterize differences in pain sensitivity and thresholds between opioid-naïve and opioid-dependent patients.
Materials and Methods: Three electronic databases were used to conduct the literature search: Pubmed, EBSCO host, and SCOPUS. A total of 372 abstracts were reviewed, of which 46 studies were deemed relevant and are included in this review.
Results: Specific gene alterations that were shown to affect postoperative pain control included single nucleotide polymorphisms in the mu, kappa, and delta opioid receptors, ion channel genes, cytotoxic T-cells, glutamate receptors and cytokine genes, among others. Alcoholism, obesity, and smoking were all linked with genetic polymorphisms that altered pain sensitivity. Opioid abuse was found to be associated with a poorer response to analgesics postoperatively, as well as a risk for prescription overdose.
Conclusion: Although pain perception has multiple complex influences, the greatest variability seen in response to opioids among postoperative patients known to date can be traced to genetic differences in opioid metabolism. Further study is needed to determine the clinical significance of these genetic associations.
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Stryker Orthopaedic Modeling and Analytics (SOMA): A Review
Walter Schmidt, MSc, Senior Manager, Modeling & Simulation Department, Sally LiArno, PhD, Senior Staff Engineer, Andreas Petersik, PhD, Doctor of Engineering, Stryker Orthopaedics, Mahwah, New Jersey, Anton Khlopas, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Due to the differences in bone morphology between demographics such as age, gender, body mass index, and ethnicity, the development of orthopaedic implants requires a large number of anatomical data from various patient populations. In an effort to assess these demographic variations, Stryker Orthopaedic Modeling and Analytics (SOMA) has been developed. SOMA is a suite of tools which utilizes a comprehensive database of computed tomography scans (CT-scans), plus associated three-dimensional (3D) bone models, allowing the user to assess population differences in bone morphology, bone density, and implant fit for the purposes of research and development. Several additional software tools are currently in development to further analyze bone density and have the potential to enhance component fit. These tools, in combination with the database, have been previously utilized for development of many implant designs and techniques in hip and knee arthroplasty, as well as in trauma surgery.
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A Comparative Effectiveness Study for Non-Operative Treatment Methods for Knee Osteoarthritis
Frank R. Kolisek, MD, Hip and Knee Surgeon, Charles Jaggard, MS, Clinical Trial Manager, Department of Orthopaedic Surgery, OrthoIndy Hospital, Greenwood, Indiana, Anton Khlopas, MD, Clinical Research Fellow, Assem A. Sultan, MD, Clinical Research Fellow, Nipun Sodhi, BA, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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A number of non-operative treatment options are commonly prescribed for patients presenting with degenerative osteoarthritis of the knee, where surgery is not yet recommended. However, there is a paucity of studies evaluating the comparative effectiveness of these treatment options to best inform both patients and providers. This study examined the comparative effectiveness of a home exercise program versus bracing or a combination of the two (brace-only, exercise-only, and brace and exercise cohorts) on the following: 1) objective functional measures (quadriceps muscle strength, Self-Paced Walk Test [SPWT], and Timed “Up & Go” [TUG] Test); 2) subjective functional measures (Lower Extremity Function Scale [LEFS] and Health Survey [VR-12] outcomes); 3) pain using Visual Analog Scale [VAS-10]; 4) patient metrics (patient treatment preference, perceptions, and compliance); and 5) progression to total knee arthroplasty (TKA) over a 12-week period. Subjects exhibited significant improvements from baseline on all measures regardless of group assignment; however, the only significant difference between groups was the larger improvement in pain scores between the brace-only and the exercise-only cohorts (p = 0.022). The brace-only regimen may be more efficacious; however, larger studies are needed to confirm this. These findings suggest that patients who are provided with either treatment option may be able to achieve a better quality of life and return to activity that may delay an elective joint arthroplasty surgery.
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Ten-Year Clinical and Radiological Outcomes of 100 Total Hip Arthroplasty Cases with a Modern Cementless Dual Mobility Cup
Loïc Laurendon, MD, Doctor of Surgery, Service de chirurgie orthopédique, Hopital Nord, CHU Saint Etienne, France,, Rémi Philippot, MD, PhD, Professor of Surgery, Thomas Neri, MD, PhD, Doctor of Surgery, Bertrand Boyer, MD, PhD, Doctor of Surgery, Service de chirurgie orthopédique, Frédéric Farizon, MD, Professor of Surgery, Service de chirurgie orthopédique, Hopital Nord, CHU Saint Etienne, and Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM), Université Claude Bernard Lyon 1, Université Jean Monnet Saint Etienne, France
985
Introduction: The original cementless Sunfit® dual mobility cup (SERF, Décines, France) exhibited limited osseointegration due to its hydroxyapatite and alumina coating. We hypothesized that replacement of the alumina with plasma-sprayed titanium + hydroxyapatite and improvement of the external geometry (Sunfit TH®) would not increase the risk of aseptic loosening. The primary goal of this study was to determine the survivorship and clinical and radiological outcomes among patients with the Sunfit TH® implant.
Material and methods: This was a single-center, prospective study of the first 100 consecutive total hip arthroplasty (THA) cases performed using the combination of a press-fit Sunfit TH® dual mobility cup and a cementless straight stem. All of the cases were primary THA and the posterolateral approach was used. The patients underwent regular clinical and radiological monitoring. Radiological measurements were carried out using OsiriX® software (Pixmeo, Geneva, Switzerland).
Results: As of the final follow-up, 19 patients had died and 4 could not be contacted. Of the remaining patients, there were zero cases of aseptic loosening, dislocation or intraprosthetic dislocation (IPD). The survivorship was 100% at 10.03 years of follow-up. No significant implant migration was measured on radiographs.
Conclusion: The excellent long-term outcomes with the Sunfit TH® cup are likely due to the use of plasma-sprayed titanium + hydroxyapatite in the coating and the addition of supplementary ridges and grooves to the outside of the cup. The absence of aseptic loosening, dislocation and IPD further confirms the high stability and good survivorship that can be achieved with these implants. We believe dual mobility cups should be used in patients above 60 years of age and in those below 60 years of age with a high risk of postoperative instability.
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All-Inside Technique for ACL-Reconstruction using a FlipCutter® and the TightRope® System
Nicos Papaloucas, MD, Consultant Orthopedic Surgeon, Orthopedic Department, Aretaeio Hospital, Nicosia, Cyprus
988
There have been many innovations in the field of ACL-reconstruction over the years, including the FlipCutter® and TightRope® system (both from Arthrex Inc.). The FlipCutter® is a combined guide pin and reamer that allows minimally invasive socket-creation from the inside out, especially in difficult-to-reach areas. The TightRope® is a further development of the well-known Endobutton™ (Smith & Nephew plc) that consists of a four-point knotless locking system. Its main advantage is its adjustability, which makes it possible to fill the entire bone socket with the graft without any empty space.
The all-inside technique using a FlipCutter® and TightRope® offers several advantages:
1. No additional accessory portals and no hyperflexion of the knee are necessary during creation of the femoral canal. Using the FlipCutter®, which is a “retro drill,” an outside-in technique is applied. This avoids the problems that arise when using the anteromedial portal for creation of the femoral canal.
2. The thickness of the femoral wall can be accurately measured before drilling.
3. There is no empty space in the femoral canal.
4. Only one tendon is needed. Usually only the semitendinosus tendon is used.
5. There is no need for a tibial canal through the cortex.
The procedure starts with diagnostic knee arthroscopy to confirm the ACL-tear and to address any possible additional meniscal or cartilaginous lesions. Graft harvest and preparation (usually only the semitendinosus tendon is needed) is then performed. Next, the knee is prepared by creation of a femoral canal: after the entry point of the femoral canal is localized, while viewing through the medial portal with the knee held at 90° of flexion, the femoral canal is created using the appropriate femoral guide and a FlipCutter®. The tibial canal is then created using the tibial guide and a FlipCutter®. Finally, the graft is passed through the medial portal to the femoral socket and stabilized with the TightRope®. The tibial end is passed through the tibial canal and stabilized with a TightRope® ABS Button.
In summary, this all inside technique for ACL- Reconstruction using FlipCutter® and TightRope® offers several advantages over traditional techniques, including no need for hyperflexion or an additional accessory medial portal while creating the femoral socket, accurate measurement of the whole thickness of the femoral condyle before drilling, the possibility of minor changes according to the desired femoral canal length, the ability to achieve no empty space in the femoral canal between the graft and bony canal, and the need for only one tendon (semitendinosus). Additionally, with this technique, the surgeon can easily place isometric sockets in the femur and tibia.
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Biological Intercalary Reconstruction with Bone Grafts After Joint-Sparing Resection of the Lower Limb: Is this an Effective and Durable Solution for Joint Preservation?
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Francesca Totti, MD, Resident, Maurizio Scorianz, MD, Specialist in Orthopedics and Traumatology, Guido Scoccianti, MD, Specialist in Orthopedics and Traumatology, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, Department of Orthopaedic Oncology and, Reconstructive Surgery, University of Florence, Azienda Ospedaliera, Universitaria Careggi, Florence, Italy, Antonio D’Arienzo, MD, Specialist in Orthopedics and Traumatology, Francesco Rosario Campo, MD, Specialist in Orthopedics and Traumatology, Carmine Citarelli, MD, Specialist in Orthopedics and Traumatology, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and, Traumatology, Pisa, Italy, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Department of Pediatric Orthopaedic Oncology, University of Florence, Azienda Ospedaliera, Universitaria Careggi, Florence, Italy
991
Due to advances in neoadjuvant therapies and preoperative imaging modalities, joint-sparing resections have become appealing in bone tumor surgery. However, the intercalary reconstruction of metadiaphyseal bone defects of the femur and the tibia after juxta-articular tumor resection remains challenging. Both biological and prosthetic reconstructions have been used for joint-sparing resections, but little is known about the long-term outcome of these procedures.
The authors reviewed a consecutive series of 64 patients treated with joint-sparing intercalary resection and reconstruction with bone grafts. Inclusion criteria were an osteotomy line within 5 cm from the knee and ankle joint surface and an osteotomy line proximal to 1 cm below the lesser trochanter at the hip level. Intra-epiphyseal resection was performed in 25 patients (39%)and intercalary resection was performed in 39 (61%). Reconstruction included 49 allograft + vascularized fibular graft (VFG), 10 allografts, and 5 VFG + structural allogenic grafts. At a mean follow-up of 117 months (range 12-305), 51 patients (80%) were continuously disease-free, and 6 showed no evidence of disease after treatment of local recurrence or metastatic lesion. One patient was alive with lung metastases at 26 months of follow-up and six patients died of disease.
In the entire series of 64 patients, 26 had a non-oncological complication that required surgical revision (40.6%). Overall survival (OS) of reconstruction was 92% at 5 years and 90% at 10 and 15 years. Limb salvage survival (LSS) was 94% at 5, 10 and 15 years.
Twenty-two fractures occurred in 17 patients (26.5%). There were a total of nine non-unions (14%). Six patients (9.3%) presented early wound dehiscence (average 1.8 months, range 0-6). A deep infection occurred in 3 cases (4.7 %).
In 12 patients treated with VGF reconstruction (12/54:22%), a donor-site complication was observed. The overall Musculoskeletal Tumor Society (MSTS) functional score in 54 evaluable patients, who were alive with reconstruction in situ, was 27 points (range 18-30).
Biologic intercalary reconstructions with bone grafts resulted in effective joint-sparing resections of the lower limb, allowing joint preservation in all but one case who required a total knee replacement for varus osteoarthritis. Despite the high rate of complications requiring surgical revision, at 15 years, overall survival of the reconstruction was 90% and limb salvage survival was 94%. In our experience, revision-free survival was better with VFG reconstruction than with allograft alone and the combination of VFG and allogenic graft seems to favor spontaneous fracture-healing and to decrease the non-union rate.
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Use of Neuromuscular Electrical Stimulation During Physical Therapy May Reduce the Incidence of Arthrofibrosis After Total Knee Arthroplasty
Chukwuweike U. Gwam, MD, Research Fellow, Tanner McGinnis, BS, Research Fellow, Jennifer I. Etcheson, MS, MD, Research Fellow, Nicole E. George, DO, Research Fellow, Anil Bhave, PT, Director of Physical Therapy, Ronald E. Delanois, MD, Director, Hip, Knee, and Shoulder Surgery, Steven F. Harwin, M.D, Chief, Adult joints reconstruction, Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland, Assem A. Sultan, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
993
Introduction: Arthrofibrosis remains a major complication following total knee arthroplasty (TKA) that negatively impacts patient outcomes and exhausts healthcare resources. The use of neuromuscular electrical stimulation (NMES) has demonstrated the ability to facilitate quadriceps muscle recovery and reduce pain. Therefore, the purpose of this study was to compare TKA patients who received physical therapy (PT) and adjuvant NMES therapy versus physical therapy alone in terms of: 1) rates of manipulation under anesthesia (MUA) to treat arthrofibrosis; and 2) post-therapy range of motion (ROM).
Materials and Methods: This was a retrospective review of TKA patients from multiple institutions who underwent physical therapy versus physical therapy and adjuvant NMES therapy following primary TKA. A total of 206 patients were reviewed in the two cohorts that either received PT alone (n=86) or PT and adjuvant NMES therapy (n=120). Data regarding the requirement of MUA postoperatively for treatment of arthrofibrosis were collected for every patient. Additionally, pre- and post-therapy knee ROM data was also collected. Outcomes in both cohorts were then compared and analyzed.
Results: Lower rates of arthrofibrosis requiring MUA were recorded in patients who used NMES therapy and PT when compared to PT alone (7.5% vs. 19.8%; p=0.009). Log regression analysis revealed lower odds of needing MUA in patients who utilized NMES therapy in adjunct with PT (odds ratio [OR]=0.36; 95% CI: 0.115 to 0.875; p=0.023). Patients who received the NMES therapy were shown to have a statistically greater mean improvement in ROM when compared to those patients who did not receive NMES (+2.63, p=0.04). Log regression analysis also demonstrated that post-PT ROM decreased the odds of receiving MUA with a larger ROM (OR=92; 95% CI: 0.824 to 0.9855; p<0.001).
Conclusion: This study demonstrated that the use of NMES during PT may reduce the incidence of arthrofibrosis and improve patient ROM. Prospective, randomized controlled, and larger-scale studies are needed to validate these results. Nevertheless, this novel report demonstrated the positive outcomes for a new application of the NMES therapy.
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Sub-Trochanteric Hip Fracture Following Core Decompression for Osteonecrosis in a Patient with a Pre-Existing Contralateral Occult Femoral Neck Fracture
Ryan J. Berger, MD, Orthopaedic Surgery Resident, Connor Cole, PA, Physician Assistant, Nipun Sodhi, BA, Clinical Research Fellow, Anton Khlopas, MD, Clinical Research Fellow, Michael A. Mont, MD, Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, Assem A. Sultan, MD, Clinical Research Fellow, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
1011
We present a unique case of a 62-year-old patient with bilateral osteonecrosis of the femoral heads secondary to corticosteroid use. She presented with an occult right femoral neck fracture and was treated with percutaneous pinning of the right femoral neck and a left-sided percutaneous drilling. Despite apparent appropriate technique, the patient sustained a left sub-trochanteric hip fracture while shifting in bed in the postoperative care unit and was taken back for cephalo-medullary nail fixation. Femoral head osteonecrosis may be an under-reported risk factor for development of pathological neck fractures. We present an overview of this topic along with suggestions for joint preservation treatment of similar patients at higher risk for perioperative fracture.
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