Surgical Technology International 32nd Edition
New Online Studies
Online First - April, 2018
Video-Assisted Subcutaneous Destruction of the Sinus Tract with Vessel-Loop Drainage as Minimally-Invasive Surgical Treatment for Pilonidal Sinus Disease
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany
964
The video-assisted subcutaneous destruction of the sinus tract (VADST) is a novel, minimally-invasive technique for the treatment of pilonidal sinus disease (PSD). This is an advancement of the previously described subcutaneous destruction of the sinus tract and the removal of hairs as well as the long-term vessel-loop drainage of the wound channel (DST).
Although the first results of this operation seemed to be promising, some of my colleagues felt that the blind approach to this procedure could be its potential “weak point”. As a result of this critique, the procedure was enhanced with the subcutaneous video-assisted inspection of the natal cleft.
Throughout most steps of VADST, like the widening of pilonidal pits with mosquito and/or Pean clamps, the subcutaneous destroying of the sinus tract, lifting the skin in a natal cleft with a curette, removing the hair with a Pean clamp and a subcutaneous vessel-loop drainage, were found to be similar to DST. The new steps involve the possibility of the video-assisted control of hair vestiges and bleedings as well as the removal of hair and debris under visual control. A rigid choledochoscope from Berci (Firma Richard Wolf GmbH, Knittlingen, Germany) was used for the subcutaneous endoscopic examination of the natal cleft area. Neither gas application nor water perfusion were necessary for this step.
Three patients with simple forms of PSD, and one patient with an acute abscess formation, underwent the VADST procedure. The patients with simple forms of PSD had no adverse events during the first eight weeks postoperatively. The patient with an acute abscess formation developed a purulent inflammation that required a wide local excision with an open-wound healing.
Due to the very small number of patients in this report, we were not able to asses this technique properly. Contrary to DST, we intend to use VADST, not only for the treatment of patients with simple forms (primary pilonidal sinus without abscessed inflammation with maximal three orifices, all of them inside the navicular area), but also for the treatment of complex PSD forms.
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Indocyanine Green (Icg)-Enhanced Fluorescence for Intraoperative Assessment of Bowel Microperfusion During Laparoscopic and Robotic Colorectal Surgery: The Quest for Evidence-Based Results
Alberto Mangano, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Federico Gheza, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Liaohai Leo Chen, PhD, Visiting Research Professor, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Eleonora Maddalena Minerva, MD, Medical Doctor, Istituto Clinico Humanitas IRCCS, Milan, Italy, Pier Cristoforo Giulianotti, MD, FACS, Vice Head Department of Surgery, Professor of Surgery: Distinguished Lloyd M. Nyhus Chair in Surgery, Chief, Division of General, Minimally, Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL
966
Anastomotic leakage is a severe complication after colonic/rectal surgery. One of the most important causes of anastomotic leakage is poor vascular supply. However, microvascular impairment at the anastomotic site is very often not detected intraoperatively by observation under white light. Indocyanine green (ICG)-enhanced fluorescence is a technology that may be useful for detecting microvascular alterations and potentially preventing anastomotic leakage. The aim of this Editorial-Minireview is to briefly and critically assess the literature evidence regarding the feasibility of using an ICG fluorescent tracer for detecting microvascular changes in the perianastomotic tissue and its potential role in preventing anastomotic leakage. We focused on minimally invasive (robotic and laparoscopic) colorectal surgery. Intraoperative ICG angiography and the quantification of ICG kinetics can be used to intraoperatively reveal the tissue-perfusion status during colorectal surgery. This may be useful for intraoperatively changing a previously planned resection/anastomotic level, and conceivably decreasing the degree of anastomotic leakage. At this stage, even though ICG technology appears to be very promising and some preliminary clinical studies have suggested that certain ICG pharmacokinetic parameters may be used to predict leakage, more reliable scoring and grading tools are needed. Furthermore, in minimally invasive colorectal surgery, more randomized prospective well-powered trials are needed to properly standardize this surgical technology.
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Intracorporeal Ileocolic Anastomosis in Laparoscopic Right Colectomy: A New Way to Make it Simple?
Giorgio Lisi, MD, Resident, Department of General and Pancreatic Surgery, University Hospital of Verona, Verona, Italy, Irene Gentile, MD, Medical Staff, Giuliano Barugola, MD, Medical Staff, Giacomo Ruffo, MD, Head of Department of Surgery, Roberto Rossini, MD, Medical Staff, Department of General Surgery, Sacro Cuore – Don Calabria Hospital, Negrar, Italy
969
Although there has been a recent increase in the use of laparoscopy in colorectal surgery, the percentage of patients who undergo surgery using entirely minimally invasive techniques is still quite low, and there are substantial differences among centers. It has been argued that the limiting factor in the use of laparoscopic procedures is not the tumor or patient characteristics, but rather the number of surgeons with adequate skills to perform an entirely laparoscopic colectomy. To address this issue, we report here our totally laparoscopic right colectomy technique, with particular focus on a new way to perform the enterotomy closure, which may simplify ileocolic anastomosis.
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Clinical Prospective Study on the Use of Subcutaneous Carboxytherapy in the Treatment of Diabetic Foot Ulcer
Lynda Khiat, MD, General Practitioner, Faculté de Médecine D'Oran, Oran, Algeria, Gustavo H. Leibaschoff, MD, Specialist in Obstetrics and Gynecology, Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
915
Diabetic footfoot ulcer (DFU) is a serious complication of diabetes mellitus, and possibly the major morbidity of the diabetic foot. It is the most common foot injury in diabetic patients and can lead to lower-extremity amputation. Management of DFU requires a systematic knowledge of the major risk factors for amputation, frequent routine evaluation, scrupulous preventive maintenance, and correction of peripheral arterial insufficiency.Carboxytherapy refers to the subcutaneous injection of CO2 to improve the microcirculation and promote wound-healing by stimulating the microcirculation. Since optimal ulcer-healing requires adequate tissue perfusion, it is considered that carboxytherapy could be useful in the treatment of DFU.The present prospective clinical study included 40 patients with different sizes and types of chronic DFU. In addition to cleaning of the wound, antibiotics and debridement as necessary, the treatment protocol included blood sugar control, medication, healthy habits, no weight-bearing, and carboxytherapy. The results showed that this treatment that included carboxytherapy promoted wound-healing and prevented amputation. These positive effects should be confirmed through a complete study that includes different clinical and instrumental parameters.
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Antimicrobial Efficacy of a Silver Impregnated Hydrophilic PU Foam
Steven L. Percival, PhD, CEO and Professor, 5D Health Protection Group Ltd., Liverpool Bio-Innovation Hub, Liverpool, United Kingdom
962
A novel hydrophilic polyurethane (PU) foam dressing which is impregnated with silver chloride, Optifoam® Gentle (OG) Ag+ (Medline Industries Inc., Chicago, Illinois), was evaluated in this study. The aims of this study were to determine the rate of elution of silver from the foam dressing over a period of 168 hours into simulated wound fluid and an evaluation of antimicrobial efficacy using zone of inhibition (ZOI), direct kill, and time-kill viability. Thirty-two microorganisms associated with wounds including Pseudomonas aeruginosa, Methicillin sensitive Staphylococcus aureus (MSSA), Acinetobacter baumannii, Candida albicans, and antibiotic-resistant strains (Methicillin-resistant S. aureus [MRSA] and Vancomycin-resistant Enterococci [VRE]) were evaluated. Silver release from the wound dressing showed an exponential curve with a stable sustained release of 25ppm achieved after 24 hours, which was maintained for the full duration of the study. OG Ag+ caused inhibition zones ranging from 4–16mm after a 24-hour contact time. In the direct kill assay, OG Ag+ reduced the microbial numbers below the limit of detection and reduced viability by a log of four within 24 hours. For the time-kill viability studies, the results support the use of this hydrophilic polyurethane foam as a wound dressing for use in wounds at risk of infection or infected by achieving a four log kill within six hours and a six log kill in 16 hours. In conclusion, OG Ag+ was shown to be an effective wound dressing in the killing of a range of important opportunistic pathogens of relevance to wound healing and infections. Achieving a six log kill against S. aureus and E.coli, within 16 hours in the time kill assay, (ASTM E2315-03) demonstrates that OG Ag+ should be an important addition to the armoury available for the management of acute and chronic wounds at risk of infection or clinically infected.
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Using Multi-Layer Foam Dressing to Prevent Pressure Injury in a Long-Term Care Setting
Kevin Woo RN, PhD, FAPWCA, Associate Professor, Faculty of Health Sciences, School of Nursing, Queen’s University, Kingston, Canada
973
Maintaining skin integrity is espoused by several international authorities as a benchmark for patient safety and quality of care. National guidelines advocate the use of prophylactic multi-layer foam dressings over bony prominences for the prevention of pressure ulcers or injuries. The purpose of this study was to evaluate the implementation of best practice guidelines including the use of multi-layer foam dressings for the prevention of pressure injuries. The analysis involved data from a total number of 62 unique patients. The incidence rate prior to the implementation of best practices was 5.2%. The incidence after the implementation was 0%.
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A Prospective Clinical and Instrumental Study on the Effects of a Transcutaneous Cosmeceutical Gel that is Claimed to Produce CO2
Gustavo H Leibaschoff, MD, Gynecologist, President of International Consulting in Aesthetic Medicine (ICAM), President of the International Union of Lipoplasty, Dallas, TX, Luis Coll, MD, Dermatologist, Director of the Center of Research in Video Capillaroscopy, Buenos Aires, Argentina, Wendy E. Roberts, MD, FAAD, Generational and Cosmetic Dermatology, Rancho Mirage, CA
976
Carboxytherapy is the therapeutic use of carbon dioxide (CO2) in its gaseous state. Since 1933, carboxytherapy has referred to either the subcutaneous injection of CO2 or percutaneous application in a warm bath. The present clinical study was performed to determine if there were any changes in the dermis after the application of a transcutaneous gel, which is claimed to produce CO2, and, if so, how these changes compared to those with CO2 injection. Ten patients received transcutaneous treatment with the gel on one side of the face and the other side without any product was used as a control. We used videocapillaroscopy with an optic probe (VCSO) to evaluate the changes in the microcirculation of the skin. VCSO was performed for the treated right and untreated left ear lobes in each patient. VCSO was performed before treatment was started (VCSO1) and after 7 days of treatment (VCSO2).A comparison of VCSO1 to VCSO2 showed an increase in the microcirculation, an increase in vertical and horizontal capillaries, and a reduction in the area of ischemia. These results are similar to those observed in other studies with CO2 injection. In conclusion, use of this transcutaneous CO2 gel produced changes in the dermis similar to those observed with subcutaneous injection of CO2.
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Managing the Diabetic Foot Ulcer: How Best Practices Fit the Real 2018 United States
Nicole Ilonzo, MD, Resident, Munir Patel, MD, Resident, Surgical Department, Mount Sinai St. Luke’s – West Hospitals, New York, New York, John C. Lantis 2nd, MD, FACS, Chief of Vascular and Endovascular Surgery, Vice Chairman of General Surgery, Director of Surgical Clinical Research, Mount Sinai St. Luke’s – West Hospitals, New York, New York
911
Diabetes Mellitus is a serious systemic illness that has an epidemic-like increasing prevalence in the United States, as well as the rest of the world. With the increasing number of people with diabetes comes the higher incidence of diabetes-related complications. One of these known complications, diabetic foot ulcers (DFU), has an estimated lifetime incidence of 15% in diabetics. Having a DFU increases the risk of infection, amputation, and even death, which is why prompt treatment and surveillance of such ulcers is imperative. Multiple organizations and journals have recently published best practices to heal and close DFU. Despite these guidelines, it is estimated that only 50% of all diabetic foot ulcers close within one year in the United States. To further confuse this picture, many trials include postoperative wounds that behave in a very different way than chronic wounds. The management of diabetic ulcers requires an understanding of not only the pathophysiology along with a multi-modal approach involving local wound care, pressure prevention, infection control, and, in some, revascularization, but also how care is delivered in the United States presently. In this review, we hope to elucidate the current knowledge and modalities used in ulcer management and to focus on key areas and best practices to inform the clinician, both in what they should do and what they can do.
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Practical Application of Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) in Patients with Wounds
Dr. Harold Brem, MD, FACS, Chief, Division of Wound Healing and Regenerative Medicine, Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ, Raelina Howell, MD, Clinical Research Fellow, Theresa Criscitelli, EdD, RN, CNOR, Assistant Vice President Administration, Ayelet Senderowicz, Clinical Research Volunteer, Nicolle Siegart, BA, Laboratory Technician,Scott Gorenstein, MD, FACEP, Clinical Assistant Professor, Clinical Director, Brian Gillette, PhD, Research Scientist NYU Winthrop Hospital, Mineola, NY
977
Rapidly evolving advances in wound-care technologies and treatment modalities, including locally injectable granulocyte-macrophage colony-stimulating factor (GM-CSF), are increasingly being used. Based on its role in the stimulation and recruitment of key contributors to wound healing, such as keratinocytes, macrophages, and fibroblasts, GM-CSF is considered to play an essential role in the wound-healing cascade. Synthetic GM-CSF has been shown to have a positive effect on the healing of chronic wounds when given as a local injection in a small number of patients. Subsequent randomized, controlled trials demonstrated that GM-CSF accelerated the healing of chronic wounds. This paper reviews the proposed mechanism of action of GM-CSF in wound healing. We also describe its method of application in the operating room at a tertiary care center for patients with wounds.
Key Messages: Many types of chronic wounds have an altered keratinocyte and macrophage function that can be potentially assuaged by the addition of locally injected growth factor therapy to standard-of-care treatment. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been shown to be beneficial for the treatment of chronic, non-healing wounds. This article reviews the data on GM-CSF, reports a proposed mechanism of action, and describes its use by a team of wound surgeons.
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Latest Advances in Cardiac Valvular Replacement
Ruggero De Paulis, MD, PhD, Professor of Surgery, Salvatore D’Aleo, MD, Cardiac Surgeon, Ilaria Chirichilli, MD, Cardiac Surgeon, Luca Paolo Weltert, MD, Cardiac Surgeon, Heart Surgery Division, European Hospital, Rome, Italy
918
The original monograph on valvular prostheses in Surgical Technology International was published in 1993. It represents a milestone and a reference point for critically organizing information on a complex and rapidly evolving topic. The last update was published in 2010.
Since then, there have been significant developments regarding both “traditional” surgical prosthesis and valves for transcatheter implantation.
Both bioprostheses and mechanical prostheses continue to evolve with respect to both their design and materials to further optimize hemodynamics and prevent a patient-prosthesis mismatch.
Each type of prosthesis has its own Achilles’s heel: limited durability leading to structural failure for bioprostheses, and the need for anticoagulation for mechanical prostheses. After a long period of only marginal improvements, new techniques for tissue preservation and manufacturing seem to have placed surgeons on the verge of a minor revolution regarding bioprostheses. In addition, in the realm of mechanical prostheses, the many promises of silicon-free pyrolitic carbon still need to be confirmed, while an extremely cautious approach with new anticoagulants has left patients out of the non-dose-adjusted revolution, which has radically improved the quality of life of other patients, such as those suffering from atrial fibrillation.
On the other hand, transcatheter therapies are maturing, and the next few years will probably see an even stronger shift in the treatment of patients away from surgical theaters to cath labs, or perhaps to a new mixed theater (which could lead to a new mixed surgeon/catheter expert professional).
This paper provides device descriptions and images of the technologies that are considered to be predominant, at least for the moment, to help orient surgeons and to serve as a reference for students. This report would not have been possible without the prior work of Profs. Denton Cooley and Eric Jamieson.
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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
965
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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Using Multi-Layer Foam Dressing to
Prevent Pressure Injury in a Long-Term Care Setting
Kevin Woo RN, PhD, FAPWCA,
Associate Professor,
Faculty of Health Sciences,
School of Nursing,
Queen’s University, Kingston, Canada
973
Maintaining skin integrity is espoused by several international authorities as a benchmark for patient safety and quality of care. National guidelines advocate the use of prophylactic multi-layer foam dressings over bony prominences for the prevention of pressure ulcers or injuries. The purpose of this study was to evaluate the implementation of best practice guidelines including the use of multi-layer foam dressings for the prevention of pressure injuries. The analysis involved data from a total number of 62 unique patients. The incidence rate prior to the implementation of best practices was 5.2%. The incidence after the implementation was 0%.
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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
928
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
940
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
942
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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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
963
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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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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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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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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