Surgical Technology International
42nd Edition
September 2023 - ISSN:1090-3941
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Avoiding Lateral Laxity in Robotic Arm-Assisted Total Knee Arthroplasty—A Surgical Technique Describing a New Method of Gap Capture and Balancing Strategy
A B Suhas Masilamani, MS (Ortho), DNB (Ortho), Praharsha Mulpur, DNB (Ortho), Tarun Jayakumar, MS (Ortho), Rajeev Reddy Kikkuri, MS (Ortho), Adarsh Annapareddy, MS (Ortho), A V Gurava Reddy, M Ch, FRCS1, Sunshine Bone and Joint Institute, Hyderabad, India
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Introduction: Optimal flexion-extension gap balancing is an important factor in outcomes after total knee arthroplasty. Knees with varus deformities are commonly associated with a greater degree of lateral laxity both in extension and flexion. Residual lateral laxity could be encountered by surgeons during component trialling after robotic-assisted total knee arthroplasty (RATKA), necessitating additional medial soft tissue release for a thicker insert. This study describes a new technique of gap assessment during RATKA and we propose a functional alignment based balancing strategy to avoid residual lateral laxity.
Materials and Methods: This surgical technique was prospectively employed in 105 patients undergoing primary MAKO® (Stryker, Kalamazoo, Michigan) RATKA for osteoarthritis of the knee with varus deformity, between January 2021 and July 2021. Patients included had an initial lateral extension laxity of more than 24mm. Surgical data points collected consisted of characterization of the laxity profile of the knee using the medial and lateral extension and flexion initial gap captures, final gap captures after dynamic balancing with a functional alignment strategy, and residual lateral extension gap laxity in millimeters at the end of implantation.
Results: The mean initial lateral extension gap was 25.76mm (standard deviation [SD]=1.47) and the mean lateral flexion gap was 24.4mm (SD=1.94). Balance was achieved in all the patients with a 9 or 11mm insert, with a mean residual lateral laxity of 0.51mm (SD=0.73, range 0–2mm). The majority of patients (n=66, 62.85%) had zero lateral laxity at the end of final implantation while 24 patients (22.8%) had 1mm of residual lateral laxity.
Conclusion: Residual lateral joint laxity can be avoided consistently and predictably in RATKA cases with initial gap capture of up to 30mm in lateral extension and flexion with this new technique of gap capture and employing various steps of balancing strategy described.
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Use of Ion Beam Enhanced Deposition (IBED) Titanium Nitride for Knee Arthroplasty Implants
Jacob S. Alexander, MD, Jason M. Hurst, MD, Michael J. Morris, MD, Adolph V. Lombardi Jr., MD, FACS, Keith R. Berend, MD, David A. Crawford, MD, JIS Orthopedics, New Albany, Ohio
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Introduction: For much of recent history, the metal-bearing surface in total knee arthroplasty has not changed much, with cobalt-chromium being the most widely-used material. However, due to the presence of nickel in its composition, much research has been done to develop alternative metal-bearing surfaces for patients with metal sensitivity. Titanium nitride coatings have shown improved performance and resistance to abrasive wear when compared to their counterparts, thus making this material an ideal alternative to current implant technology.
Materials and Methods: Rigorous testing was undertaken to analyze the mechanical properties of titanium nitride for use as a coating in orthopedic implants, such as scratch adhesion, hardness, modulus, and wear rates with specialized machinery, including a Tribometer®, Nano Indenter® G200 (KLA Corporation, Milpitas, California), and scratch system.
Results: Across all properties tested—abrasive wear resistance, wear resistance, cohesive and adhesive failure load, hardness, and modulus—IBED TiN coatings were shown to be dominant to both uncoated CoCr and uncoated Ti-6Al-4V in a significant manner.
Conclusion: The use of IBED TiN coatings offers a way to improve the performance of mechanical components, such as orthopedic implants made from Ti-6Al-4V materials. IBED TiN coatings can enable the use of Ti-6Al-4V as an alternative to CoCr for articulating orthopedic implant devices, such as knee arthroplasty.
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Mako™ Robotic-Arm Assisted Medial Unicompartmental Knee Arthroplasty: Surgical Technique from the Office to the Operating Room
Frederick F. Buechel, Jr. MD, Michael A. Mont, MD, Northwell Health, Lenox Hill Hospital, New York, New York, Nathan R. Angerett, DO, Zhongming Chen, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Rushabh M. Vakharia, MD, Maimonides Medical Center, Brooklyn, New York, Robert C. Marchand, MD, Ortho Rhode Island, Wakefield, Rhode Island
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The utilization of robotic-arm assisted unicompartmental knee arthroplasty (UKA) or partial knee arthroplasty (PKA) for the treatment of medial unicompartmental osteoarthritis has continued to increase. This is in part due to the consistently reproducible accuracy and precision of implant planning, intra-operative ligament balancing software, tracking optimization software, robotic-arm assisted bone preparation, excellent survivorship rates, and improvements in many patient-reported outcomes compared to manual UKA, using the Stryker Mako™ Robotic Partial Knee System (Stryker, Mako Surgical Corp., Mahwah, New Jersey). Training in the utilization of robotic-arm assistance can be time-consuming and comes with an associated learning curve even after the in-person training and coursework is complete, like most procedures. Therefore, our aim was to describe the pre-operative planning and intra-operative surgical technique for using a robotic-arm assisted partial knee system for UKA/PKA in patients who have unicompartmental medial knee osteoarthritis. Specifically, we will discuss: 1) pre-operative planning; 2) operative setup; 3) intra-operative steps; 4) execution of the plan; and 5) trialing, implantation, and final assessments.
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Isolated Tibial Polyethylene Insert Exchange After Total Knee Arthroplasty for Treatment of Instability and/or Polyethylene Wear
Jacob S. Alexander, MD, Eleanor Richardson, David A. Crawford, MD, Keith R. Berend, MD, Michael J. Morris, MD, Adolph V. Lombardi, Jr., MD, FACS, JIS Orthopedics, New Albany, Ohio
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Introduction: Isolated tibial polyethylene insert exchange (ITPIE) as a treatment for instability and polyethylene wear after total knee arthroplasty (TKA) remains controversial with studies reporting varied results. The purpose of this study is to evaluate the survival and outcomes of ITPIE performed for treatment of instability with or without polyethylene wear after TKA.
Materials and Methods: A query of a private practice arthroplasty registry revealed 364 patients (390 knees) treated with ITPIE for instability and/or polyethylene wear after TKA between 1997 and 2019. Mean age was 66.8 years, mean body mass index (BMI) was 33.8 kg/m2, and 59% of patients were female. ITPIE for infection, tibiofemoral aseptic loosening, arthrofibrosis, poor wound healing, and extensor mechanism failure were excluded. All patients had well-fixed and well-aligned components prior to surgery.
Results: Mean follow up was 5.9 years. Knee Society Clinical (KSC) scores improved preoperatively from 55 to 76 postoperatively (p< 0.001). Thirty knees (7.7%) required re-revision: 15 (3.8%) for ongoing instability, seven aseptic loosening, three infection, two patellofemoral maltracking, one patellar fracture, one metal allergy, and one revised elsewhere for cause unknown. Kaplan-Meier analysis revealed survival of 93.1% (95% CI: ±1.5%) at five years, 84.7% (95% CI: ±3.5%) at 10 years, and 80.5% (95% CI: ±4.4%) at 21 years.
Conclusions: ITPIE is a reliable treatment for instability and/or polyethylene wear after TKA in the presence of well-fixed and well-aligned components with good survival and clinical improvement. The less invasive nature and reduced risk for bone loss make it an attractive option versus full revision.
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Mid-Term Survivorship, Radiographic and Functional Outcomes of Robotic-Assisted Unicompartmental Knee Arthroplasty
Martin W. Roche, MD, Tsun Yee Law, MD, MBA, Hospital for Special Surgery Florida, West Palm Beach, Florida, Rushabh M Vakharia, MD, Holy Cross Hospital, Fort Lauderdale, Florida, Kevin L. Mekkawy, DO, Maimonides Medical Center, Brooklyn, New York, Hugo C. Rodriguez, DO, MBS, Resident Physician, Larkin Community Hospital, South Miami, Florida
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Introduction: The use of robotic-arm assistance for medial unicompartmental knee arthroplasty (RAUKA) has become an area of interest to overcome technical challenges, improve accuracy, and optimize patient outcomes. Due to the rise in osteoarthritis (OA) and robotic assistance, well-powered long-term studies are warranted. The aim of this study was to analyze midterm survivorship, radiographic changes, range of motion (ROM), and patient-reported outcome measurements (PROMs) of RAUKA.
Materials and Methods: Patients who underwent RAUKA for medial compartmental OA were identified from April 2009 to May 2014. The query yielded 162 knees with a mean follow up of 6.5 years. Primary endpoints were to compare survivorship, final mechanical axis alignment, radiographic changes, mean ROM, and changes to the following PROMs: Knee Society Score (KSS), International Knee Documentation Committee (IKDC), and Oxford Knee Score (OKS). Statistical analyses were primarily descriptive. A p-value less than 0.05 was considered statistically significant.
Results: There were no revisions of the primary implant, one case required exchange of polyethylene bearing and debridement for deep infection, and five cases required additional surgical intervention with implant retention. Overall survivorship was 100%. Radiographic assessment demonstrated no mechanical loosening or osteolysis surrounding the implant. Mean ROM was 3 to 121.9º. Patients demonstrated a mean functional KSS of 78.55, IKDC of 78.22, and OKS of 43.94.
Conclusions: The study supports excellent mid-term outcomes in patients undergoing RAUKA for medial compartment OA. Longer term follow-up studies are necessary to determine the efficacy of this technology for patients undergoing RAUKA for medial compartment OA.
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Mid-term Follow Up of a Highly Porous Acetabular Component for Primary Total Hip Arthroplasty
Walter B. Beaver, MS, MD, Michael Bates, MD , Bradley S. Ellison, MD, Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC, J. Ryan Martin, MD, Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, Nipun Sodhi, MD, Department of Orthopaedic Surgery, Long Island Jewish Medical Center; North Shore, University; Northwell Health, New York, NY, Michael A. Mont, MD, Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Baltimore, MD
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Introduction: As implant technology has continued to improve over the past decade, there has been an increase in the utilization of highly porous metal substrate acetabular components for primary total hip arthroplasty (THA). These implants have several theoretical benefits including a lower modulus of elasticity, which may result in a reduction in stress shielding, a higher coefficient of friction, which may enable better initial implant fixation, as well as higher porosity that may facilitate improved biological fixation. Although these components are implanted frequently, there are some studies that have posed concerns regarding radiographic evidence of loosening. Therefore, the purpose of this study was to assess: 1) The quality of fixation of porous metal acetabular components based on radiographs; 2) clinical outcomes; and 3) revision rates.
Materials and Methods: A total of 159 patients (169 hips) who had undergone a primary THA utilizing a porous metal primary acetabular cup with minimum two-year follow up were assessed. The study cohort consisted of 51% women, had a mean age of 65 years (range, 30 to 92 years), a mean body mass index (BMI) of 29kg/m2 (range, 15 to 54), and a mean follow up of approximately four years (range, three to six years). Acetabular revision for component failure was documented. Radiographic assessments were independently performed by two fellowship-trained arthroplasty surgeons to determine implant stability and radiolucencies. Clinical evaluations were made by assessing the hip disability and osteoarthritis outcome score (HOOS-Jr) survey scores. Failure was defined as the need to revise the acetabular component, for either septic or aseptic pathology.
Results: At final follow up, one patient had definitive loosening, one had probable loosening, and three patients had possible loosening. Only 3.0% had radiolucencies or radiosclerotic lesions in at least one zone. Of these patients, three developed progressive radiolucencies. All patients achieved excellent postoperative HOOS-Jr scores, and no significant differences were noted between patients who did not have loosening compared to patients who had possible or probable loosening. Only two patients underwent revision for aseptic loosening of the cup (success rate for this implant was 98.8% [2/169]).
Discussion: There is a paucity of studies focused on the results of this porous metal substrate acetabular component, with some of the current literature reporting conflicting outcomes. Our study reported a low acetabular revision rate of only 1.2% at an approximate mean follow up of four years. The incidence of radiolucencies and progressive radiolucencies were lower (3.0%) than has been found in some studies. Overall, the results of this study support the utilization of this acetabular component in appropriately indicated patients.
Conclusion: These data show a low rate of acetabular revision at mean four-year follow up.
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Imaging Threshold for Assessment of the Correct Reduction in the Treatment of Unstable Syndesmotic Injuries – A Retrospective Analysis of 57 CT Scans
Florian Radetzki, PD Dr. med. habil., Papuna Tsirekidze, MD, Joachim Zagrodnick, MD, Department of Orthopedic and Trauma Surgery, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
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Introduction: An incongruence of the distal tibiofibular joint (TFJ) after treatment of upper ankle joint injury represents a prearthrotic deformity and must be corrected. The objectives of this study were to analyze postoperative CT scans after surgical treatment of unstable syndesmotic injuries, and to determine the prevalence of syndesmotic malreduction and its contributing factors. The specific parameters of three-dimensional imaging for objective detection of malreduction should be identified as a helpful intraoperative imaging threshold.
Materials and Methods: Postoperative CT scans of 57 patients were analyzed by identifying cases requiring correction. Factors that influenced the reduction result (patient age, sex, fracture type and surgeon qualifications) were evaluated. The following CT measurements were determined: anterior (AD) and posterior tibiofibular distance (PD), TFJ width, anteroposterior fibular translation (APT), length and rotation of the fibula, position of the malleoli to the talar joint surface. A confidence interval of 95% was assumed (significance level p < 0.05).
Results: A very high proportion of the cases required revision (38.5%). Age (p=0.199), sex (p=0.752), body mass (p=0.722), and fracture type (p=0.266) had no significant influence on the reduction result. The risk of requiring correction was slightly lower for well-experienced trauma surgeons. The measurements revealed the following thresholds: AD: ø 3.2 mm (±2.2), PD: ø 5.1 mm (±2.2), TFJ: ø 3.4 mm (±1.4), APT: ø 7.9 mm (±3.5), and rotation: ø 10.7° (±6.8). The fibula was too long in 4 cases (7%) and too short in 8 cases (14%). There was a malleolar incongruence in 5 cases (8.7%). The analysis revealed a significant correlation between the ratio of the anterior and posterior tibiofibular distances and a need for correction.
Conclusion: The ratio between the anterior and posterior tibiofibular distances in the axial sectional image is an aid for intraoperative assessment of the correct reduction in the TFJ.
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A Novel Distal Biceps Rupture Repair Technique Utilizing a Biocomposite Scaffold
David Le, DO, Inspira Medical Center, Vineland, NJ, USA, Sean McMillan, DO, Virtua Willingboro and Camden Campuses, Virtua Health System, Marlton, NJ, USA
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Distal biceps tendon ruptures are uncommon injuries that have a re-rupture rate of 1.2% - 6%. In severe traumatic injuries or chronic injuries, a distal biceps tendon repair may require augmentation due to insufficient tissue quality. Unsuccessful treatment of these injuries can result in the loss of approximately 40% of supination strength and 30% of elbow flexion strength. There has been a growing interest in biologic augmentation in orthopedic surgery, and its incorporation into distal biceps tendon repairs has increased as well. Established bio-inductive implants and dermal allografts have been shown to be of benefit; however, these biologics have drawbacks such as failure to incorporate at time of implantation, lack of structural strength, and technical difficulty of implantation. The BioBrace® (ConMed, New Haven, CT) is a bio-inductive, biocomposite scaffold that is composed of highly porous type I collagen and bio-resorbable poly (L-Lactide) (PLLA) microfilaments. It can be used in conjunction with distal biceps tendon repair or reconstruction. It has the advantage of providing strength to the augmented repair at time zero of implantation, while also demonstrating the ability to induce new organized tissue growth throughout its resorptive phase. We describe a technique to successfully augment a distal biceps tendon repair using the BioBrace®.
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Surgical Technique: Core Decompression of Femoral Head Osteonecrosis with Bone Marrow Aspirate Concentrate
Tyler Edmond, MD, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, Daniel Hameed, MD, Devin Olsen, DO, Jeremy Dubin, BA, Michael A. Mont, MD, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Nicolas S. Piuzzi, MD, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Osteonecrosis of the femoral head is a progressive and potentially debilitating disorder that is responsive to core decompression, especially in early-stage disease. This is typically accomplished through use of an 8 to 10mm trephine or multiple, small-diameter percutaneous drilling. Use of the large diameter trephine is associated with risk of fracture and may not allow healing across large gaps. Here, we present a technique for core decompression using percutaneous drilling that allows bone marrow aspiration concentrate to be introduced. We used the aspirate needle to decompress the femoral head osteonecrotic lesion, followed by the administration of bone marrow aspirate concentrate. This is a straightforward procedure that can be used with low risk for patient morbidity.
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Robotic-Arm Assisted Lateral , Unicompartmental Knee Arthroplasty: Case Series with Minimum Five-Year Follow-Up
Kevin L. Mekkawy, DO, Holy Cross Orthopedic Research Institute, Holy Cross Health, Fort Lauderdale, Florida, Hugo C. Rodriguez, DO, MBS, Tsun Yee Law, MD, MBA, Martin W. Roche, MD, Hospital for Special Surgery, West Palm Beach, Florida , Rushabh M. Vakharia, MD, Maimonides Medical Center, Brooklyn, New York
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Introduction: Lateral unicompartmental knee arthroplasty has been shown to be a successful treatment modality for isolated lateral osteoarthritis (OA) of the knee. The reproduction of proper knee kinematics, limb alignment, as well as proper soft tissue balancing and component positioning have been shown to be of the utmost importance for a successful unicompartmental knee arthroplasty (UKA). Robotic assistance has shown to be a reliable tool in order to replicate these factors, as compared to manual instrumentation alone. Recent studies have shown the potential of robotic-assisted surgery in controlling these surgical factors for medial UKA; however, studies assessing outcomes of robotic-assisted lateral UKA (RAUKA) are lacking. Therefore, a retrospective single-center study was performed to assess outcomes of lateral RAUKA.
Materials and Methods: Patients who underwent lateral RAUKA from a single surgeon at a central institution between January 2008 and June 2017 were identified. All patients received a lateral UKA with a fixed-bearing metal backed onlay tibial component. Patients over the age of 18, with at least a five-year follow-up and a lateral UKA were contacted by phone and asked a series of questions to determine satisfaction and survivorship. Each patient was asked in a “yes” or “no” manner, if they have had their implant revised or reoperated for any reason, and a 5-point Likert scale was used to assess satisfaction.
Results: Data was collected from 50 patients (53 knees). Of the patients that responded: 32 (60%) were right knees; 32 (60%) were female, and average follow-up was 7.6 years (5–14 years). Of the 53 knees, one had a revision (98% survivorship). Excluding the revision, 51 (98%) of the included cases were either “very satisfied” or “satisfied” with their surgery.
Discussion/Conclusions: Robotic-arm assisted lateral UKA was found to have high survivorship and a satisfaction rate in patients that had at least a five-year follow-up. In the future, larger prospective comparison studies with longer follow-ups are necessary to adequately compare survivorship and satisfaction rates of robotic-assisted lateral UKA to conventional UKA.
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Total Knee Arthroplasty in a Patient with Ipsilateral Painless Hip Arthrodesis: Technical Surgical Tips and a Novel Method for Intraoperative Navigation-Assisted Planning
Itay Ashkenazi, MD, Akram Habibi, MD, Ran Schwarzkopf, MD, MSc, Professor, NYU Langone Health, New York, NY, USA
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Total knee arthroplasty (TKA) in the setting of a previous ipsilateral hip fusion/arthrodesis is an uncommon and challenging procedure. There is little information available in the literature on the challenges and techniques available to perform TKA in these patients. For a traditional TKA procedure, the patient is placed in the supine position and various knee-positioning devices are used to allow for adequate knee and hip flexion, which is required for surgical exposure and tibia preparation. Ipsilateral hip arthrodesis presents two major challenges: (1) Hip flexion is crucial for adequate knee flexion while the patient is supine during the TKA procedure, and (2) the use of advanced technology, specifically computer navigation and robotic-assisted surgery techniques, is limited due to the inability to acquire the hip center of rotation during surgery, due to the lack of hip motion. Therefore, equipment and positioning must be adjusted by the surgeon to facilitate TKA in these patients. This article reports the case of a 72-year-old male patient with a long-standing, painless right hip arthrodesis, presenting with end-stage osteoarthritis of the right knee, leg-length discrepancy, and an 11.6° difference between the mechanical and anatomical axes of the femur. We describe the unique surgical planning as well as the surgical positioning options that allow for adequate knee flexion and proper surgical exposure. Furthermore, we describe a novel method of computer-assisted navigation for intra-operative planning and execution utilizing a reflected tibia as a template for the distal femoral cut.
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Lower Rates of Femoral Fracture and Subsidence with a Morphometric Stem in Cementless Total Hip Arthroplasty
Gloria Coden, MD, Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, Brandon Naylor, DO, Advanced Center for Joint Surgery, Cumming, Georgia, Daniel Hameed, MD, Michael A. Mont, MD, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for , Matthew S. Hepinstall, MD, Advanced Orthopedics, Baltimore, Maryland, Department of Orthopedic Surgery, NYU Langone Health, New York, New York,
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Introduction: A “morphometric” tapered femoral stem with size-specific medial curvatures and proportional neck lengths was introduced, attempting to improve fixation and biomechanics in cementless total hip arthroplasty (THA) across a range of femoral sizes and morphotypes. We investigated whether this design reduced complications and better restored anatomy (e.g., limb length and offset) compared to a traditional tapered stem with consistent neck lengths across sizes.
Materials and Methods: We reviewed 389 THAs (340 patients) performed using either of two cementless femoral implants. Records were reviewed for demographics, surgical details, complications, and reoperations. Radiographs were examined for subsidence, biologic fixation, leg lengths, offset, and proximal femoral morphology.
Results: The intraoperative fracture rate was lower with this morphometric stem compared to this traditional stem (0 vs. 3.4%), as was the incidence of postoperative subsidence ≥3mm (4.7 vs. 19.2%). With the numbers available, no differences were identified regarding rates of reoperation for periprosthetic femur fracture (0 vs. 1.0%) and femoral fixation failure without fracture (1.1 vs. 0%), or all-cause reoperations (2.7 vs. 2.4%). Limb length and offset restoration were similar with the two implants, but the shortest available femoral head was used less frequently with this morphometric stem compared to this traditional stem (22 vs. 54%).
Conclusions: This morphometric stem was associated with decreased rates of intraoperative fracture and postoperative subsidence, along with decreased use of the shortest available head. Nevertheless, both implants demonstrated clinical success, allowing reconstruction of limb length and offset with low rates of femoral fixation failure.
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Use of Remote Physiologic and Therapeutic Monitoring Following Total Knee Arthroplasty
Nipun Sodhi, MD, Long Island Jewish Medical Center, New York, New York, Daniel Hameed, MD , Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Robert L. Barrack, MD , Washington University School of Medicine, Saint Louis, Missouri, Andrew M. Schneider, MD, The University of Chicago, Chicago, Illinois, Anil Bhave, PT, Sinai Rehabilitation Center, Rubin Institute for Advanced, Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, Michael A. Mont, MD, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Introduction: Remote physiologic monitoring (RPM), or remote therapeutic monitoring (RTM), has grown exponentially for the management of chronic medical diseases in Medicare patients. More recently, the application of this technology has ventured into the orthopaedic arena, and more specifically, for total joint arthroplasty. Platforms to expedite this monitoring can provide continuous biodata feedback on digital biomarkers to patients and surgeons, which can potentially help improve and create novel patient-specific recovery pathways. Furthermore, various devices developed for this monitoring might help obviate the need for frequent emergency room visits, readmissions, and prolonged outpatient physical therapy sessions, as well as reduce complications and increase patient satisfaction scores after total joint arthroplasty surgery. However, while there are a number of potential benefits to technology for this type of care, its application following total knee arthroplasty has not been well-studied. Therefore, after an overview of the usage of RPM and RTM, the purpose of this study was to review the current literature regarding three common remote monitoring technologies: 1) smartphone apps; 2) wearables; and 3) combined smartphone apps and wearables. We also considered the potential financial implications of remote physiologic monitoring.
Materials and Methods: A comprehensive search of the PubMed, Cochrane Library, MedLine, and Web of Science databases was performed. Three main subgroups of monitoring devices were included for analysis: smartphone apps, wearable devices, and combined wearable plus smartphone app platforms. Searches focused on remote physiologic monitoring, patient-specific advantages, financial advantages, billing and coding options, as well as overall efficacy of platforms.
Results: The current review found smartphone apps, wearables, and combined smartphone app and wearable platform technologies to be advantageous in the postoperative period following total knee arthroplasty. The wearable components can provide highly accurate and reproducible data, which the user-friendly smartphone app can relay to the patient so they can easily understand their progress. Additionally, through the apps, patients can directly access their surgical team. By constantly collecting and evaluating range of motion and functional data, the surgical team can identify if the patient is appropriately progressing through treatment or if further intervention is warranted.
Conclusion: The incorporation of the remote physiologic monitoring devices during the post-total knee arthroplasty period shows strong promise as a progress-tracking modality. Published benefits include reduced physical therapy visits, decreased pain scores and reliance on opioids, increased activity levels as assessed by step counts, increased ability to follow less well-performing patients, reduced readmissions, reduced in-person clinic visits, and decreased postoperative costs.
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Sex-Specific Postoperative Outcomes of Primary Total Hip Replacements: The Performance of Total Hip Replacement Procedures Leads to Worse Outcomes in Men
Mitchell K. Ng, MD, Adam Gordon, MD, Matthew Magruder, MD, Che Hang Jason Wong, MD, Maimonides Medical Center, Brooklyn, New York, Alex M. Fong, MD, Zhongming Chen, MD, Michael A. Mont, MD, Lenox Hill Hospital, New York, New York, Sandeep S. Bains, MD, DC, MBA, Jeremy A. Dubin, BA, Daniel Hameed, MD, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Introduction: The demand for primary total hip arthroplasty (THA) is expected to increase significantly in the coming years, and women are expected to account for the greatest proportion of this increased demand. The purpose of this study was to determine, using a national database, the effect of sex on 90-day outcomes in primary THA patients while matching for confounding variables. Specifically, we evaluated: (1) in-hospital lengths of stay; (2) 90-day readmission rates; (3) 90-day medical complications; (4) and total global 90-day episode-of-care (EOC) costs in men and women.
Materials and Methods: Using the 100% Medicare Standard Analytical Files (SAF), a query from January 1, 2005 to March 31, 2014 from a nationwide database was performed to analyze patients who received a primary THA. The series was divided into two cohorts: men (n=436,737) and women (n=436,737). Male and female patients were matched according to age and Elixhauser-Comorbidity Index (ECI). Uni- and multi-variable regression analyses were performed to analyze the effects of sex on in-hospital lengths of stay, 90-day readmission rates, 90-day medical complications, and total global 90-day EOC costs.
Results: Men had greater overall 90-day medical complications compared to women following primary THA (1.28 vs. 1.19%, p<0.001). Men were found to have higher rates of acute kidney failure (0.12 vs 0.05%, p<0.0001), acute pancreatitis (0.02 vs. 0.01%, p<0.0001), cerebrovascular accidents (0.03 vs. 0.01%, p<0.0001), deep vein thromboses (0.06 vs. 0.04%, p<0.0001), and myocardial infarctions (0.02 vs. 0.01%, p<0.0001). Women were found to have higher rates of acute post-hemorrhagic anemiae (0.31 vs. 0.30%, p<0.001) and urinary tract infections (UTI; 0.40 vs. 0.28%, p<0.0001) compared to men. Men had shorter in-hospital lengths of stay (LOS) (3.42 vs. 3.54 days, p<0.001) but greater 90-day readmission rates (7.67 vs. 6.39% p<0.0001). Both cohorts had similar total global 90-day EOC costs ($14,869.85 ± $12,333.50 vs. $14,957.34 ± $10,915.61, p=0.36).
Conclusion: Men undergoing THA have a greater number of overall 90-day medical complications and readmission rates while women have higher incidence of UTI, post-hemorrhagic anemia, and longer LOS. Understanding sex-based differences in complication rates and outcomes can help surgeons with preoperative counseling and targeted preoperative optimization.
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Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint , Arthroplasty – Literature-Supported Guidelines
Maximillian P. Ganz, DO, MS, Northwell Orthopaedic Institute, Huntington Hospital, Huntington, NY, Jonathan R. Danoff, MD, Schwartz Ambulatory Surgery Center, Northwell Orthopaedic Institute North Shore University Hospital, Manhasset, NY, Bradley Gerber, MD, Assistant Professor, Long Island Jewish Valley Stream Hospital, Valley Stream, NY, Keith R. Reinhardt, MD, FAAOS, Northwell Orthopaedic Institute, South Shore University Hospital, Babylon, NY, Michael Ciminiello, MD, Peconic Bay Medical Center, Riverhead, NY, Giles R. Scuderi, MD, Professor, Donald and Barbara Zucker School of Medicine At Hofstra/Northwell, Hempstead, NY
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Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.
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Anterior Cruciate Ligament Reconstruction and Accelerated Rehabilitation with InternalBrace™ Augmentation in a Professional Footballer
Adam Stokes, MSc, ScribePro, Glasgow, United Kingdom, Tony Tompos, PgDip, Scottish Rugby Union, Edinburgh, United Kingdom, Graeme P. Hopper, MBChB, MSc, MRCS, MFST, MD, FRCS (Orth), NHS Lanarkshire University Hospitals, Scotland, United Kingdom William T. Wilson, MBChB, BSc (MedSci), MRCS, MFSEM (UK), FRCS (Orth), University of Strathclyde, Glasgow, Scotland, Gordon M. Mackay, MD, FRCS (Orth), Professor, University of Stirling, Scotland, United Kingdom
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Introduction: Interest in anterior cruciate ligament (ACL) repair has been increasing as an alternative to traditional reconstructive techniques and encouraging results have been demonstrated using internal bracing with suture tape augmentation (FiberTape®, Arthrex, Naples, Florida). ACL repair is challenging if the rupture is mid-substance or distal. We describe the case of a hybrid ACL reconstruction with internal brace augmentation.
Materials and Methods: This retrospective case report documents the rehabilitation process of a 31-year-old professional footballer who had an isolated ACL rupture. The patient underwent a hybrid ACL reconstruction with bone-patellar tendon-bone autograft and suture tape augmentation 10 days after his injury. A task-based rehabilitation programme defined by six progressive phases relevant to performance-based outcome measures was undertaken. Each phase had clear, functional, progressive goals incorporating exercises to improve mobility, neuromuscular control, strength, and a progressive return to running and sport-specific movements.
Results: Using the rehabilitation framework outlined, this player produced excellent results in all objective criteria postoperatively and was able to return to unrestricted full team training in under five months (146 days) following surgery.
Conclusions: This case presentation demonstrates the safe and accelerated return to professional football following ACL reconstruction augmented with internal bracing. The player was able to meet all criteria-based aspects of return to play.
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Safety of Cryoneurolysis as a Preoperative Treatment for Total Knee Arthroplasty (TKA)
Sean McMillan, DO, Virtua Health, Virtua Medical Group Burlington, New Jersey , Julian Zangrilli, DO, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, Andrew Amedee, MD, Vinod Dasa, MD, Louisiana State University Health Sciences Center, New Orleans Louisiana
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Cryoneurolysis is a minimally invasive procedure that utilizes extreme cold temperature to achieve thermal neurolysis of peripheral sensory nerves. This study aimed to evaluate the safety of cryoneurolysis as a preoperative treatment for total knee arthroplasty (TKA) and assess the incidence of major and minor wound complications associated with the procedure. A retrospective chart review was conducted on 357 patients who underwent cryoanalgesia within two weeks of their scheduled TKA. The study found that cryoneurolysis as a preoperative treatment for TKA did not demonstrate an increased incidence of major complications, including acute periprosthetic joint infections, skin necrosis, or permanent treatment site nerve damage/neuroma compared to published rates of infection. Complications were minimal, with only three cases of infection and five cases of superficial cellulitis observed; however, none were directly attributable to the cryoneurolysis procedure. These findings are encouraging and suggest that cryoneurolysis is a relatively safe adjunct procedure with a similar risk of major or minor complications when used as a preoperative treatment for TKA.
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Risk Analysis of Restrictive Factors for Fast-Track Knee Arthroplasty—A Retrospective Study of 1,224 Patients
Ivana Mehlhorn, MD, University Hospital Halle (Saale), Halle, Germany, David Wohlrab, MD, Professor, Professor Karl Stefan Delank, MD, Trauma and Reconstructive Surgery, University Hospital Halle, (Saale), Halle, Germany, Florian Radetzki, PD Dr Med Habil, Dessau Medical Center, Brandenburg Medical School, Theodor Fontane, Dessau, Germany
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Introduction: With the implementation of a fast-track principle as an interdisciplinary and multimodal concept, an accelerated convalescence and reduction of postoperative complications and a reduction of hospital stay can be achieved. This has been shown not only to increase patient satisfaction but in reduction of hospital cost as well. However, the concept cannot be successfully implemented in all patients. Patients who require an extended length of stay (LOS) after surgery can profit from optimizations of postoperative care and rehabilitation as well. Therefore, early identification of such patients is desirable. This case control study aimed to identify patient characteristics and patient-independent factors that may affect fast-track programs and lead to extended length of stay in knee arthroplasty.
Materials and Methods: From October 2007 to May 2013, 1224 patients were treated at the University Hospital Halle (Saale) with a total knee arthroplasty (TKA). A maximum stay of seven days was defined as the target of the “fast-track arthroplasty” concept. There were 164 patients (13%) that did not reach this timeframe and were assigned to the case group (n=164). Each case group patient was compared to a patient with an inpatient stay of seven days or less who was operated on the same day and by the same surgeon. These patients formed the control group (n=164). In addition to causes for extended LOS, metadata (age, sex, body mass index [BMI]), chronic nicotine and alcohol abuse, American Society of Anesthesiology (ASA) score, blood transfusion necessity, and comorbidities were determined. The statistical analysis included two sample t-tests, a chi-square test, and logistic regression analyses. Additionally, 95% confidence intervals were calculated (p<0.05).
Results: Gender distribution in both groups showed no differences (case group: 40.2% male, 59.8% female vs. control group: 32.3% male, 67.7% female). The ø age in the case group was 69.6 ± 8.7 years, significantly higher than that of the control group with 66.5 ± 9.4 years (p=0.002). Another difference between the groups was seen in the need for red blood cell transfusion (case group 51.2%, control group 39.6%, p=0.03). The need for postoperative antibiotic therapy was associated with a 3.741-fold risk of prolonged hospital stay. ASA score and BMI were identical in both groups. For the patients with positive nicotine abuse, the regression analysis showed a 2.465-fold risk of prolonged length of stay. Alcohol abuse did not appear to play a role in length of stay in our patient cohort.
For pre-existing conditions, patients from the case group were more likely to have a cardiac burden than those from the control group (p=0.03). The most common causes of prolonged LOS were elevated CRP followed by effusion and delayed wound healing. Conclusion: The study shows that especially patient age, the presence of cardiac secondary diseases, nicotine consumption, and patient-independent factors like blood loss could have a negative influence on convalescence. Despite constant cost reductions in the healthcare system, the concept of “fast track arthroplasty” should always be adapted to the specifics of each individual patient in view of increasing patient age or critically questioned already preoperatively.
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Modified Lightbulb Non-Vascularized Bone Grafting Technique for Osteonecrosis of the Femoral Head
Tyler Edmond, MD, University of Maryland School of Medicine, Baltimore, Maryland, Daniel Hameed, MD, Devin Olsen, DO, Jeremy A. Dubin, BA, Erica Grynovicki, PA-C, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Multiple techniques for non-vascularized bone grafting for the treatment of femoral head osteonecrosis have been proposed with varying degrees of success. The success of these procedures may be improved with the use of ancillary growth and differentiation factors. The trephine (Phemister) technique allows for limited decompression of the femoral head through two percutaneous tunnels, while the direct approach through the femoral head (“trapdoor” technique) may result in damage to the articular cartilage. Herein we provide our modified “lightbulb” technique to decompress the femoral head through a window at the femoral head-neck junction that provides excellent, direct access to the osteonecrotic lesion. Adjuvant, non-vascularized bone graft, comprised of bone marrow aspiration concentrate (BMAC) and open matrix bone graft (MagnetOs Flex Matrix, Kuros Bioscience, Bilthoven, Netherlands) is a unique fibrillar and flexible structure that provides bone induction and further structural support to create a favorable environment for bone formation and healing. This is a straight-forward, hip-preserving, surgical technique that may be used for symptomatic management to delay, or potentially obviate, the need for total hip arthroplasty in patients who have medium- to large-sized or early-collapse lesions of the femoral head.
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The Role of Three-Dimensional Custom Printing in Revision Total Hip Arthroplasty
Katy Kim, MBChB, BSc, Nemandra A. Sandiford, MRCS, MSc, MFSEM, FRCS(Tr/Orth) Southland Hospital, Kew, New Zealand
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Acetabular revision accounts for approximately 18% of all total hip arthroplasty (THA) procedures. This was the third most common reason for THA revision in 2020. One of the unique challenges faced by reconstruction surgeons performing revision THAs is the issue of acetabular bone loss. The aim of this paper is to present the role of custom acetabular reconstruction with marked bone loss for undergoing revision THA, using a local case study as an example.
We described utilization of custom components to address the highly complex cases with Paprosky classification of III and above. Recent studies have shown comparable clinical results to conventional methods and improvement of postoperative patient-rated outcome scores. However, larger clinical trials focusing on the long-term outcomes in comparison to off-the-shelf components in complex acetabular revisions would be of merit.
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A Novel Achilles Tendon Repair Technique Utilizing a Bio-Composite Scaffold for a Sub-Acute Tear
Harrison A. Patrizio, BS, Charles J. Middleton, BS, Rowan University School of Osteopathic Medicine, Stratford, NJ, Rex W. Lutz, DO, Jefferson Health NJ, Stratford, NJ, Lauryn Bianco, DO, Inspira Health Network, Vineland, NJ, Sean McMillan, DO, Virtua Willingboro and Camden Campuses, Virtua Health System, Marlton, NJ
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Achilles tendon ruptures are prevalent musculoskeletal injuries accounting for 20% of all large tendon ruptures with a re-rupture rate of 2.1–8.8%. Ineffectual management of these injuries can lead to a significant loss in push-off strength and overall ankle function. The field of orthopedic surgery has shown an increasing interest in biologic augmentation. Encouraged by its success in various other applications, this approach holds promise for potentially enhancing outcomes in Achilles tendon repairs, especially in poor tendon tissue. The BioBrace® (ConMed, New Haven, Connecticut) is a biocomposite scaffold made of highly porous type I collagen and bioresorbable poly (L-Lactide) (PLLA) microfilaments. It can be applied in conjunction with Achilles tendon repair or reconstruction. It provides immediate strength to the augmented repair upon implantation and simultaneously promotes new, organized tissue growth throughout its resorptive phase. Here, we outline a technique to effectively augment an acute Achilles tendon repair utilizing the BioBrace® reinforced bio-inductive implant.
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