Surgical Technology International
41st Edition
December 2022 - ISSN:1090-3941
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Early Outcomes of a Universal Femoral Component with an Ultracongruent Insert
Jesua I. Law, DO, Valley Orthopaedic Bone & Joint, Modesto, California , Robert B. Erlichman, MD, Jason M. Hurst, MD, Michael J. Morris, MD, David A. Crawford, MD, Keith R. Berend, MD, Adolph V. Lombardi Jr., MD, FACS, Joint Implant Surgeons, Inc., New Albany, Ohio, Angela M. Grant, ASN, A3, Hofmann Arthritis Institute, Salt Lake City, Utah, Valley Orthopaedic Bone & Joint, Modesto, California , , 4White Fence Surgical Suites, New Albany, Ohio, 5Mount Carmel Health System, Columbus, Ohio
1601
Introduction: A primary total knee arthroplasty (TKA) system was introduced with a modern universal femoral design with a wide range of size and constraint options to accommodate a variety of patient anatomy, while incorporating streamlined instrumentation for maximum operating room efficiency and economy. The purpose of this study is to review the early clinical outcomes and survivorship at minimum two-year follow up with this knee system.
Materials and Methods: From September 2015 to December 2019, 797 patients (1004 knees) underwent primary total knee arthroplasty (TKA) at our center with the TJO Klassic® Complete Primary Knee System (Total Joint Orthopedics Inc., Salt Lake City, Utah) with ultracongruent bearings and were available for study with minimum two-year follow up. All office and hospital records were reviewed for patient demographics, preoperative and postoperative clinical assessments, including range of motion, Knee Society Scores (KSS), University of California at Los Angeles (UCLA) activity scales, complications, and reoperations.
Results: Mean follow up was 3.1 years (range, 2–6; standard deviation [SD] ±1.0). There were 471 female patients (59%) and 326 male patients (41%). Mean age at surgery was 69.3 years and mean body mass index was 32.9kg/m2. An all-polyethylene tibial component was used in 305 knees (30.4%) while a modular titanium tibial baseplate with polyethylene insert was used in 699 (69.6%). The patella was left unresurfaced in 381 knees (37.9%). KS scores, including pain component, clinical, and functional, as well as UCLA scores, all improved significantly (p<0.001). Two patients (3 knees) underwent revision. One patient required two-staged revision for treatment of infection in both knees, and one patient required patellar revision for aseptic loosening. Kaplan-Meier survival at 6.2 years was 98.4% (95% CI: ±0.97%) to endpoint of revision of any part for any cause and 99.6% (95% CI: ±0.36%) to endpoint of aseptic revision.
Conclusions: At early minimum two-year follow up, this modern universal complete knee system used with ultracongruent bearings demonstrates excellent clinical outcomes and survival.
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Revision Distal Femoral Replacement for Patello-Femoral Maltracking: A Surgical Technique
Oliver C. Sax, DO, MS, Austin Nabet, DO, Thomas Novack, MD, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland Ronald E. Delanois, MD, James Nace, DO, MPT, Michael A. Mont, MD, Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
1578
The use of the distal femoral replacement (DFR) has grown in recent years. Historically, this procedure was reserved for malignancy and complex revision cases with relative success. In recent years, complex reconstruction cases have had relative success. DFR has been associated with a range of complications including anterior knee pain, patellar instability, limitations in knee motion, and rotational instability that are sequelae of altered patello-femoral mechanics. Thus, subsequent dysfunction may require revision. To our knowledge, no surgical technique to correct DFR patello-femoral maltracking has been demonstrated in current literature. We present a surgical technique for DFR patello-femoral maltracking corrected surgically with femoral component revision and femoral stem retention.
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Enhanced Mid-Resection Workflow Technique for Severe Varus Deformity Correction Using Robotic-Arm Assisted Total Knee Arthroplasty
Suhas Masilamani, AB, MBBS, MS, DNB , Praharsha Mulpur, MBBS, DNB , Adarsh Annapareddy, MBBS, MS, Kushal Hippalgaonkar, MBBS, DNB , AV Gurava Reddy, MBBS, D.Orth, DNB, FRCS, M.Ch , Sunshine Bone and Joint Institute, Sunshine Hospitals, Hyderabad, India, Martin W. Roche, MD, Hospital for Special Surgery, West Palm Beach, Florida
1612
Introduction: Robotic technology in total knee arthroplasty has been proven to improve accuracy of component positioning, achieve alignment targets, and balance the knee objectively. However, the utility of robotics in correction of severe varus deformities of the knee has not been investigated in detail. The aim of this paper was to establish the utility and describe the technique of robotic-arm assisted total knee arthroplasty (RA-TKA) in achieving pre-balance in severe varus deformities of the knee.
Materials and Methods: Among the existing Mako (Stryker, Kalamazoo, Michigan) RA-TKA workflows, pre-resection workflow is limited to knees which can be pre-balanced by component positioning according to functional alignment. Mid-resection workflow (distal femur/tibia first) is reserved for complex cases, whereby the extension gap is balanced first. In our experience, both workflows could not achieve pre-balance in severe varus deformities, necessitating the need to develop a novel technique. The ability of the robot to execute precise bone cuts allows for a provisional postero-medial femoral bone cut in flexion, giving access to remove large inaccessible posterior osteophytes and the tight posterior capsule, thus balancing the knee in extension. The flexion gap is subsequently matched to the extension gap by alterations in axial component positioning.
Conclusion: This novel “enhanced mid-resection workflow” technique establishes the utility of the RA-TKA in balancing severe varus deformities of the knee. We also propose an algorithm which simplifies and helps surgeons choose between the three workflows to pre-balance knees irrespective of the severity of the varus deformity.
A Reamer by Another Number: What Do They Actually Measure?
Jacob S. Alexander, MD, Michael J. Morris, MD, Adolph V. Lombardi Jr., MD, FACS, Keith R. Berend, MD, David A. Crawford, MD, JIS Orthopedics, New Albany, Ohio
1635
Acetabular reamers are a mainstay in the preparation of the acetabulum in total hip arthroplasty. Many surgeons, however, have noticed a discrepancy in the preparation of the socket and the reported size of reamers during this crucial phase of the procedure. A cross-sectional study performed by measuring a variety of sets of acetabular reamers was performed. The results showed that 17 of 21 sizes (81%) measured at least 2mm less than their reported size. Given that these differences beget unintended consequences, the industry may consider replacing or sharpening reamers already in use or even switching to a single-use reamer model.
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Arthrozheal®, a Bioactive Fibrin Scaffold for Joint Cartilage, Tendon and Soft Tissue Lesions. Latest Results and Application Perspectives
George A. Skarpas, MD, PhD, Assistant Professor, University of Patras, School of Health Rehabilitation, Achaia, Greece
1636
Treatment of articular cartilage, tendon and soft tissue damage remains a challenge for the practicing orthopaedic surgeon. Due to the multifactorial aetiology of these lesions, there is a narrow therapeutic window within which they can be treated successfully, thus preventing progression to other musculoskeletal tissues. Recently, a new material that combines platelet-rich fibrin with collagen and is applied as a gel scaffold (ArthroZheal®, Vivostat A/S, Allerød, Denmark) has been shown to provide unique results in these patients.
We arthroscopically treated 210 patients (114 knees, 32 hips, 52 shoulders, 12 ankle joints) with ArthroZheal®. The basic idea was to adjust treatment to the individual patient and to repair related and/or contributing problems before or along with treatment of chondral/tendon/ligament injuries. Arthroscopy was our preferred surgical method; the goal was to restore and preserve function, alleviate pain and minimise progression to osteoarthritis. We excluded cases of inflammatory arthropathy, unstable or malaligned joint, “kissing lesions” (bipolar), infection, obesity, massive rotator cuff rupture and multiligament instability.
Our results were more than promising. We observed improved mobility in 93%, reduced pain in 95% at 3 months and further improvement at 6 months, with near-normal ROM (97% ) and pain-free status (98%). The MRI at 12 months post application showed cartilage restoration/reformation in 94% of patients, improved cartilage quality (84% )-by 2nd-look arthroscopic confirmationand normal tendon or ligament reconstruction (without stitching of the affected area)(95%). We were concerned about bone marrow oedema and rehab compliance among elderly patients.
For successful regeneration of tissue lesions and osteochondral defects, natural gel bioscaffolds, combined with platelet rich fibrin (PRF) with chondroinductive and osteoinductive growth factor stimulators (ArthroZheal®) are required. There is no “gold standard” in the treatment of cartilage defect/tissue lesions or preferred treatment option. Many algorithms are used, which mostly rely on the surface area of the defect/site of lesion and on surgeon experience. An important issue is that rehabilitation depends on the treatment mode used and on the defect/lesion characteristics (classification and qualification). While a return to functional work and sports is possible with all procedures, different lengths of time are needed.
Effectiveness of Sensor-based Rehabilitation in Improving Outcomes in Patients Undergoing Total Knee Arthroplasty
Jing Hong Loo, Hao Han Hai, NUS Yong Loo Lin School of Medicine, Singapore, Hamid Rahmatullah Bin Abd Razak, MBBS, MMed (Ortho Surg), FRCSEd (Orth), Assistant Professor, Duke-NUS Medical School, Singapore
1600
Background: Physical rehabilitation after total knee arthroplasty (TKA) is important for long-term functional recovery. Recently, sensor-based home rehabilitation (SHR) has gained prominence as a promising method that allows monitoring and guidance that is both structured and accessible, compared to traditional methods of physical rehabilitation. Despite the advent of wearable sensor systems, there is a paucity of evidence regarding SHR in the current literature. Thus, this systematic review aimed to evaluate the effect of wearable SHR on post-TKA outcomes.
Methods: We performed a systematic search of three electronic databases from the beginning of record to March 12, 2021. Primary outcomes were patient-reported outcome measures (PROMs) after rehabilitation, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS). Secondary outcomes were physical activity levels and functional performance including range of motion (ROM) and Timed Up and Go Test (TUG).
Results: A total of 16 studies involving 1321 subjects were included. All wearable sensors in our included studies involved a combination of accelerometers, gyroscopes and magnetometers as functional units. These studies reported favourable outcomes for all three PROMs, although the extent of improvement in specific domains varied among studies. Moreover, physical activity in terms of daily steps and time spent on physical activity increased post-rehabilitation. Similarly, there were improvements in ROM and TUG that reflected a favourable post-operative trajectory during rehabilitation.
Conclusion: SHR is effective for improving subjective and objective outcomes post-TKA. The role of SHR should be evaluated by a dedicated cost-benefit analysis to facilitate its wider adoption in healthcare systems.
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Outcomes of Deep Wound Management Methods During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis
Zhongming Chen, MD, Sandeep S. Bains, MD, DC, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland Nipun Sodhi, MD, North Shore University Hospital Northwell Health, New York, New York
1609
Wound closure for total knee arthroplasty (TKA) typically focuses on promoting the most optimal healing, while preventing infection, allowing for functionality and immediate ambulation, as well as providing for excellent cosmesis. We have previously described four aspects of closure for TKA including the: (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) a specific dressing. In this systematic review and meta-analysis of the literature, we will focus on closure of the deep fascial layer. Specifically, we assessed: (1) wound complication risks of different techniques; (2) closing times of different sutures; and (3) postoperative ranges of motion depending on varying levels of knee flexion or extension. There were 12 reports on wound complication risks, closing times, and positionings. The meta-analysis demonstrated overall lower wound complication risks with the use of barbed sutures (6 versus 13%, p<0.05). It also demonstrated overall significant closing time reductions with the use of barbed sutures (p<0.05). Additionally, three out of four reports showed the positive effects of closure in flexion for TKAs, while one report was inconclusive. In conclusion, this systematic review and meta-analysis demonstrated lower wound complications, decreased closing times for barbed sutures, as well as superior outcomes for closures in a semi-flexed knee position.
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An Updated Review on Layered Closure Techniques for Total Hip Arthroplasty
Nipun Sodhi, MD1, Long Island Jewish Medical Center, North Shore University Hospital Northwell Health, New York, New York , Zhongming Chen, MD, Sandeep S. Bains, MD, DC, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland , Luke J. Garbarino, MD, Wake Forest School of Medicine, Winston-Salem, North Carolina,
1611
Introduction: One of the main concerns with total hip arthroplasty is the development of periprosthetic joint infections (PJIs). Appropriate wound closure can contribute to the prevention of PJIs with a watertight closure effectively sealing the implant from the outside. It is important to continuously investigate which materials as well as techniques are potentially the most efficacious and cost effective for wound closure. Therefore, the purpose of this review article was to critically appraise the current total hip arthroplasty wound closure materials and techniques as reported in the literature. Specifically, we evaluated: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs.
Materials and Methods: A literature search was performed using the PubMed database from inception to February 2022. The query consisted of terms including “hip, arthroplasty, wound, closure, capsular closure, fascial closure, subcutaneous closure, and skin closure.” References from selected texts were also reviewed for inclusion. Only manuscripts written in the English language were included for final analysis. A systematic review was performed for the five topics: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. Additionally, a meta-analysis was performed on the closing time of fascial approximations.
Results: The current literature supports performing a layered closure of the wound by approximating the fascial layers, which can help close any empty spaces. The techniques for closure at this layer seem to be equal regarding wound complications between running knotless barbed sutures versus interrupted throws; however, knotless sutures have the potential of a quicker closure time. A total of three out of four reports and the meta-analyses demonstrated that wound closure time can be reduced with barbed sutures, along with decreased number of sutures required as also shown by three out of four reports. The most superficial layers, subcuticular and skin, can be closed with either sutures, staples, or skin adhesives, all of which appear to have adequate outcomes. A report found that patients who had skin closure with barbed suture had faster time to a dry postoperative wound and lower rates of delayed discharge. For the overlying dressing, an occlusive and absorbent dressing can both protect the wound as well as collect any residual wound drainage. Two reports found increased dryness, decreased wound drainage, and decreased rates of delayed wound healing with use of 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh dressings. If the capsule and short external rotators are taken down during the approach, repairing these can potentially help increase postoperative hip stability as well as decrease dislocation rates.
Conclusion: The variety of materials and techniques available to close a THA wound allows surgeons to tailor closure to be patient specific. In general, the authors recommend performing layered closures from the capsule and short external rotators (if taken down during the approach), fascial layer closure with either a running knotless suture, subcutaneous closure either with the same knotless suture as the fascial layer brought more superficially, or with simple interrupted sutures to tack down any empty space, as well as finally subcuticular and skin sutures with a skin adhesive glue overtop. The skin adhesive can help provide an extra layer, particularly in active patients.
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Core Decompression Versus Nonoperative Management of Osteonecrosis of the Ankle: A Systematic Review
Ruby Gilmor, DO, MS, Zhongming Chen, MD, Michael A. Mont, MD, Ronald E. Delanois, MD, James Nace, DO, MPT, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Introduction: The purpose of this study is to investigate the efficacy of core decompression for treating osteonecrosis of the ankle, including the distal tibia and talus, compared to nonoperative management. A systematic review was performed to specifically evaluate: (1) clinical results (patient-reported pain as well as functional scores, physician clinical reported assessment); (2) radiographic outcomes (i.e., radiographic progression of collapse); and (3) need for further procedures.
Materials and Methods: A search of PubMed, EMBASE, and the Cochrane Library found eight reports that fit the inclusion criteria for core decompression or nonoperative management of osteonecrosis of the ankle. Four studies totaling 194 ankles diagnosed with osteonecrosis that underwent core decompression were analyzed. An additional four papers examined 64 ankles diagnosed with osteonecrosis that underwent nonoperative management. Level of evidence of the studies ranged from II to IV. Outcomes of core decompression and nonoperative management analyzed clinical scores such as the American Foot and Ankle Severity Score (AOFASS) and Mazur ankle grading system. Radiographic progression was studied with Ficat and Arlet as well as Hawkins scores.
Results: Overall, there was an improvement in clinical scores and decreased radiographic progression in ankles treated with core decompression. AOFASS scores rose from 41.5 + 0.7 to 89 + 0.7, while the mean Mazur score increased from 34.5 + 0.7 preoperatively to 91.5 + 0.7 postoperatively. After core decompression, only 21% (40 out of 194 ankles) progressed radiographically to Ficat and Arlet stage III or IV postoperatively. Furthermore, core decompression showed less requirement for further surgical management compared to nonoperative management.
Conclusions: Osteonecrosis of the ankle is not as commonly encountered in practice compared to other joints, such as the hips and knees. The results of this study suggest that core decompression is a successful option for treating osteonecrosis of the ankle.
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Two-Year Prospective RSA Measured Migration of a Third-Generation Taper Wedge Cementless Femoral Stem
Dermot Collopy, FRCAS,
Perth Hip and Knee Clinic,
Western Australia, Australia, Jonathan Manara, BMedSci, BMBS, FRCS (Tr&Orth),
St John of God Hospital,
Perth, Australia
1572
Introduction: Implant migration is a concern with newly designed cementless femoral stems for total hip arthroplasty. Radiostereometric analysis (RSA) is the most accurate technique available to measure implant migration following total hip arthroplasty (THA). The objective of this study was to establish the migration pattern of a cementless tapered wedge stem during the first two years after implantation using RSA as well as assess clinical results.
Materials and Methods: Thirty patients underwent a primary THA with a morphometrically designed cementless stem. RSA was completed immediately after surgery and at three-, six-, 12- and 24-month intervals. Subsidence after two years was compared to the migration thresholds, and survivorship and clinical outcome scores were obtained.
Results: After two years, the mean subsidence (distal migration) of the stem within the canal was 0.08mm (standard deviation [SD] 0.036mm), the mean retroversion was 0.301mm (SD 0.362), and the maximal total point motion was 0.764mm (SD 0.195). All stems demonstrated stable motion patterns beyond six months (p=0.99). Patient outcome data highlighted a statistical and clinically significant improvement (p<0.05) after hip arthroplasty at six months, and then there were modest changes at subsequent follow ups.
Conclusion: The femoral stem tested in this study was designed to provide adequate implant stability in total hip arthroplasty patients in the short term. We found stable fixation of the third-generation tapered wedge stem two years postoperatively and clinical improvements in patient-reported outcomes.
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Matrix-Induced Autologous Chondrocyte Implantation (MACI) is Largely Effective and Provides Significant Improvement in Patients With Symptomatic, Large Chondral Defects: A Systematic Review and Meta-Analysis
Alec D. Grossman DO, MHSA, Jason P. Den Haese Jr. DO, MS, Joshua A. Tuck DO, MS, MBA, Health Millcreek Community Hospital, Erie, Pennsylvania, Lesley Georger, PhD, D’Youville College, Buffalo, New York, Sean Mc Millan, DO, FAOAO, Virtual Health System, Marlton, New Jersey
1613
Introduction: The purpose of this study was to perform a meta-analysis for long-term patient-reported outcome (PRO) measures in Matrix-induced Autologous Chondrocyte Implantation (MACI) patients using the Knee Injury and Osteoarthritis Outcome Score (KOOS) model.
Materials and Methods: A literature search under the PubMed/Medline and Embase databases was conducted. Statistical significance was determined between the mean pre- and postoperative scores at each time point (1-, 2-, and 5-years). Cohen’s d analysis was used to measure the effect size (ES) in each group when compared to preoperative measurements to determine clinical responsiveness.
Results: KOOS subscales at all long-term postoperative follow ups measured in this study showed significant (p-value <0.001) improvement when compared to preoperative scores. Furthermore, apart from KOOS sports and recreation (KOOS-SR) at 1-year postoperative follow up that showed a medium ES (ES, 0.761), all other KOOS subscales at long-term follow up periods showed a large (>0.8) ES on mean preoperative KOOS.
Conclusion: Review of the literature demonstrate an absence of large meta-analyses for long-term PRO measures with the MACI procedure. It was found that all subscales were largely responsive when evaluated at >2 years after surgery. Based on these results, MACI is an effective treatment option for patients with symptomatic, full-thickness cartilage defects about the knee.
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Early Experience With New Femoral and Tibial Cones in Revision Total Knee Arthroplasty: A Case Series
Michael E. Kahan, DO ,Zhongming Chen, MD, Michael A. Mont, MD, James Nace, DO, MPT, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Joshua E. Drumm, DO, Providence Orthopedics and Sports Medicine, Spokane, Washington, Arthur L. Malkani, MD, University of Louisville, Louisville, Kentucky, Ronald E. Delanois, MD, Sinai Hospital of Baltimore, Baltimore, Maryland
1621
Highly porous metaphyseal cones have proven useful in revision total knee arthroplasty in providing surgeons with improved metaphyseal fixation when large contained and uncontained bony defects are encountered. In this case series, we demonstrate three patients who received the latest generation of metaphyseal cones. Specifically, these cases will highlight this new system description and its operative techniques as well as the indications for metaphyseal cone use with various real-world applications. These newer-generation porous-coated cones are excellent options for large bone defects in the absence of infection, providing adequate metaphyseal fixation without constraining final implant positioning.
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Review of a Novel Antimicrobial Wound Gel System Used in Total Knee Arthroplasty Including a Protocol for a Randomized Controlled Trial at Our Institutions
Paul W. Knapp, DO, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Zhongming Chen, MD, Michael A. Mont, MD, James Nace, DO, Rubin Institute of Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai, Hospital of Baltimore, Baltimore, Maryland, Giles R. Scuderi, MD, Orthopaedic Service Line, Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York, Ronald E. Delanois, MD, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
1627
Introduction: Surgical-site infections (SSIs) remain a challenging complication following total knee arthroplasty (TKA) with estimates nearing 2%. Current antimicrobial dressing options have gained popularity despite reported bacterial resistance and ineffectiveness. Bacteria can produce an extracellular polymeric substance (EPS), thereby rendering infections difficult to treat. Recently, a novel antimicrobial wound gel system has been developed to address EPS-associated infections. This new technology is comprised of various components that act to break bonds and cross-linking within EPS, induce lysis, and provide a moist environment to promote healing. In this paper, we provide a background of: (1) wound infections; (2) biofilms; and (3) current dressing options. We will then describe a novel antimicrobial gel therapy with a summary of a randomized control trial (RCT).
Materials and Methods: We describe an RCT protocol for patients undergoing primary TKA at two large tertiary care centers. Patients will be randomized 1:1 using permutated block methodology to either standard of care (SOC) or a novel antimicrobial wound gel system, yielding 750 patients in each treatment arm. Inclusion criteria include patients scheduled to undergo primary TKA. The primary outcome is the appearance of a surgical-site complication.
Conclusion: We briefly describe the background of wound healing and biofilm, as well as current treatment modalities including antimicrobial dressings and a novel technology developed to address the EPS component of bacteria. In addition, we describe a protocol for a randomized controlled trial examining the effects of this novel therapy on surgical-site complications in patients undergoing primary TKA.
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Minimally Invasive HEROS (Higher External ROtator Sparing) Posterior-lateral Approach for Total Hip Arthroplasty: Surgical Technique and Preliminary Results
Michele F. Surace, MD, Professor, Luca Faoro, MD, Sergio Ferraro, MD, Orthopedics and Trauma Unit, Cittiglio-Angera, asst Settelaghi, Varese, Italy, Giorgio Ippolito, MD, Michele Zitiello, MD, ICOT Hospital, Orthopedics and Trauma Unit, Latina, Italy, Christian Candrian, MD, Professor, Service of Orthopedics and Traumatology, Department of Surgery, E.O.C., Ospedale Civico, Lugano, Switzerland
1552
Background: Minimally invasive approaches for Total Hip Arthroplasty (THA) are extremely popular among both patients and surgeons. Even though many surgical techniques have been described with overall satisfactory results, one of the most feared complications that still burdens THA is early dislocation, particularly for the most popular, posterior-lateral, approach.
Objectives: The purpose of this report is to describe an original, minimally invasive, posterior-lateral technique, which spares the proximal external rotator muscle tendons of the hip (Higher External ROtator-Sparing; HEROS), while presenting its preliminary clinical and radiographic results.
Methods: From 2018 to 2020, 100 patients underwent THA, performed by the same surgeon using the HEROS technique. In all cases, the same cementless prosthesis was implanted. The Modified Harris Hip Score (MHHS) was obtained before surgery and at the last follow-up visit. The osteointegration and orientation of the prosthetic components were radiographically evaluated, and the restoration of the femoral offset was analyzed.
Results: Seventy-seven patients were assessed at a mean follow-up of 28 months. At the time of surgery, the average age of the patients was 72 years. There were 36 females and 41 males with a mean BMI of 27. The diagnoses were primary arthritis, avascular necrosis of the femoral head and fracture of the femoral neck. The mean surgical time was 76 minutes.
The average MHHS score at follow-up was excellent. The mean offset variation was approximately 1 mm. There was an intra-operative fracture and an early infection of the wound. There were no dislocations. All patients returned to activities of daily living and were satisfied with the cosmetic appearance of the wound.
Conclusions: The present study confirmed that this simple, minimally invasive approach is effective for restoring pain-free joint function and preventing implant dislocation with a low incidence of complications.
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CT Scan-Based Robotic-Arm Assisted Total Hip Arthroplasty: What Do Today’s Highest-Quality Studies Tell Us?
Zhongming Chen, MD, Sandeep S. Bains, MD, DC, MBA, Daniel Hameed, MD, Jeremy A. Dubin, BA, Jonathan M. Stern, BA, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, Nipun Sodhi, MD, North Shore, University Hospital Northwell Health, New York, New York
1634
Introduction: Total hip arthroplasty (THA) aims to restore function and reduce pain for patients suffering from hip pathologies. However, some procedures require revision THA, with the most common reasons including: mechanical failure, aseptic loosening, infection, and component malposition leading to dislocations. Computed tomography (CT) scan-based, three-dimensional imaging operating techniques can help address some of these issues by helping to provide more optimal implant positioning, which can potentially confer improved outcomes. To date, only a few studies have evaluated the utilization of CT scan-based robotic-arm assisted THA in total hip arthroplasty, and those that do are not necessarily of the high-methodological quality. Therefore, the purpose of this review was to select the most recent and good- to high-quality studies focusing on robotic-assisted THA, to help provide a more comprehensive representation of postoperative outcomes. Specifically, we evaluated each study independently as well as performed a cumulative assessment of this most recent high-quality data.
Materials and Methods: An extensive, cross-platform search of total hip arthroplasty on August 1, 2022 was performed. Studies were included only if they addressed robotic-assisted THA in comparison to manual techniques. Additional inclusion criteria consisted of studies scoring excellent (100 to 85 points) or good (84 to 70 points) based on their Coleman methodology score. Studies were evaluated as individual pieces of work, as well as a cumulative assessment. Specific outcomes evaluated were: component placement in safe zones, leg- length discrepancies, dislocation rates, clinical outcomes, patient clinical scores, patient-reported outcome measures (PROMS), lengths of stay, and costs.
Results: Overall, 24 studies were included for analyses. CT scan-based robotic-arm assisted THA had some potential key advantages as compared to manual techniques. Specifically, robotic-assisted THA was associated with more accurate component placement in safe zones, fewer chances of leg-length discrepancies, and lower risks of dislocation. Patient satisfaction and reported outcome measures were superior for CT scan-based robotic-arm assisted THA. Costs were also lower. Overall, 23 of 24 studies were positive for this technology, with one study of cases done between 2010 and 2014 more neutral. The robot led to positive findings for component placement in safe zones, leg-length discrepancies, dislocation rates, clinical outcomes, PROMS, lengths of stay, and costs.
Conclusion: The current literature suggests potential advantages for CT scan-based robotic-arm assisted THA compared to manual THA. Surgeons should consider CT scan-based robotic-arm assisted THA for their patients given the multiple added benefits of improved clinical scores and PROMS, less dislocations (with a few exceptions reported), more component placements in safe zones, less leg-length discrepancies, decreased lengths of stay, and decreased episode-of-care costs.
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Registration of Bony Landmarks and Soft Tissue Laxity during Robotic Total Knee Arthroplasty is Highly Reproducible
Ryan S. Charette, MD, Nana O. Sarpong, MD, Travis R. Weiner, BS, Roshan P. Shah, MD, Associate Professor, H. John Cooper, MD, Associate Professor, Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
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Introduction: There is growing interest and enthusiasm for robotic total knee arthroplasty (TKA). Many robotic systems require registration of bony landmarks as well as a dynamic soft tissue evaluation to plan femoral and tibial resections. Variability in this user-driven registration can introduce error and undermine the purported precision and accuracy offered by robotics. The purpose of this study was to evaluate inter- and intrarater reliability in robotic registration with a new robotic system (ROSA®; Zimmer-Biomet, Warsaw, IN).
Methods: Two unpaired cadaveric knee specimens were exposed, and optical arrays were placed into the femur and tibia. Three separate evaluators conducted repeated trials of anatomic registration and assessment of soft tissue laxity, as well as coronal alignment, sagittal alignment, femoral size, and maximum opening in the medial and lateral compartments in both flexion and extension. Repeated trials were conducted using these specimens with and without preoperative imaging for landmarking (image-based and image-free workflows). An Intraclass Correlation Coefficient (ICC) was calculated for each observer and across observers to determine intra-and interrater reliability, respectively, in robotic registration.
Results: There was good to excellent reliability for all conditions, and all correlation coefficients were >0.767. On average, ICCs for intrarater reliability were excellent for Doctor 1 (0.952), Doctor 2 (0.975), and Doctor 3 (0.925). On average, the ICCs for interrater reliability were excellent for both the “Registration + Gap Assessment” condition (0.961) and the “Gap Assessment” condition (0.994).
Conclusion: Our results show a high repeatability of registration of anatomic landmarks and gap assessment among observers using this robotic system for both image-based and image-free software.
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Tapered Modular Femoral Stems for Revision Total Hip Arthroplasty Show Excellent Mid-Term Survivorship
Christopher G. Salib, MD, MS, Oliver C. Sax, DO, MS, Sandeep S. Bains, MD, Zhongming Chen, MD, Michael A. Mont, MD, Ronald E. Delanois, MD, James Nace, DO, MPT, Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Introduction: Revision total hip arthroplasty (THA) can be challenging in the face of proximal femoral bone loss, catastrophic implant failure, or recurrent hip instability. Tapered modular femoral stems have shown substantial success at short follow up for aseptic revisions. The purpose of this study was to report mid-term revision THA outcomes of a tapered modular femoral stem at a tertiary referral center used to treat both aseptic as well as periprosthetic joint infections (PJIs). We specifically sought to assess: (1) revision-free implant survivorship; (2) patient-reported outcome measurements (i.e., Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]); (3) postoperative surgical complications and 30-day readmissions; as well as (4) radiographic outcomes.
Materials and Methods: We reviewed a consecutive series of 92 patients who underwent revision THA between 2009 and 2013 with a tapered modular femoral stem. After accounting for mortality (n=7) and loss to follow up (n=13), a total of 72 implants in 66 patients who had eight years of mean follow up (range, 2 to 11) were included. PJI (46%) was the predominant preoperative indication for revision THA, followed by aseptic loosening (25%), periprosthetic fracture (18%), and symptomatic hardware (10%). Outcomes of interest included all-cause revision-free survivorship, postoperative complications, and HOOS JR, as well as SF-12 scores. Radiographically, they were evaluated for subsidence, radiolucencies, and loosening.
Results: Aseptic revision-free survivorship of the femoral component was 95.8% (69 out of 72). Including septic cases, revision-free survivorship was 87.5% (63 cases), and 60 implants (83.3%) had an all-cause revision-free survivorship. For those patients who underwent septic revisions, eight out of nine remained infection free, while one underwent a resection arthroplasty. Furthermore, the cause for femoral aseptic revisions were subsidence (1.4%) and aseptic loosening (2.8%). Functional score improvements for HOOS JR, SF-12 PCS, as well as MCS were 29, 13, and 2, respectively (all p<0.001). There were eight emergency department visits (11.1%,) and six inpatient readmissions (8.3%). Additionally, two patients had dislocations (2.8%, two out of 72) not requiring revision. There were two cases of femoral subsidence and one aseptic loosening requiring revision; whereas, the rest did not demonstrate any progressive radiographic lucencies.
Discussion: The eight-year mean survivorship results of the tapered modular femoral stems in revision THA demonstrated excellent results. Our series found improved outcome scores and relatively low postoperative complications, which indicate a favorable implant survivorship profile for revision THA.
Conclusion: These results serve to inform arthroplasty surgeons of expected outcomes of the modular stems when used for patients who need complex revision THA.
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Influence of Kinematic Alignment on Soft Tissue Releasing and Manipulation Under Anesthesia Rates in Primary Total Knee Arthroplasty
Jacob S. Alexander, 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: Total knee arthroplasty (TKA) is typically performed to restore a neutral mechanical alignment. Recently, there has been increased interest in kinematic alignment to restore the patient’s individual alignment. The purpose of this study is to determine if kinematic balancing reduces the need for intraoperative soft tissue releases and rates of manipulation under anesthesia compared to mechanical alignment.
Materials and Methods: A query was performed between January 2021 and July 2022 to identify all patients who underwent a primary TKA that was performed with kinematic alignment (KA), which revealed 97 patients (107 TKAs). A cohort of consecutive patients from the preceding six months was gathered of patients who underwent primary TKA with mechanical alignment (MA). This cohort consisted of 199 patients (223 TKAs), yielding a total study cohort of 296 patients (330 knees). Mean age was 64.7 years, mean body mass index (BMI) was 33.1 kg/m2, and 57.1% of patients were female. Rates of manipulation under anesthesia and intraoperative release status were analyzed.
Results: Average range of motion preoperatively improved from 108.9° to 114.4° in the KA group but decreased from 112.3° to 109.9° in the MA group at six weeks (p<0.0001). Three of 107 knees (2.8%) required an additional pie-crusting of the superficial MCL in the KA group, whereas 58 of 223 knees (26.0%) did in the MA group (p<0.0001). Three of 107 knees (2.8%) in the KA group and 24 of 223 knees (10.8%) in the MA group required MUA (p<0.0001).
Conclusion: Kinematic alignment significantly reduced the need for intraoperative soft tissue releases and postoperative manipulation under anesthesia. Further studies of the influence of kinematic alignment on these outcomes across multiple surgeons should be performed and/or compared to mechanical alignment.
Validation of a Prototype Augmented Reality Navigation System for Total Hip Replacement
Jevan Arulampalam, MbiomedE, Qing Li, PhD, Professor, University of Sydney, Sydney Australia, Andrew Bucknill, A/Prof, MB BS, MSc (Dist), FRCS, FRACS, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Sanjeev Gupta, MBBS FRACS FAOrthO, Royal Prince Alfred Institute or Rheumatology and Orthopaedics, Sydney, Australia, Steve J. McMahon, A/Prof, FRACS(Orth), Malabar Orthopaedic Clinic, Monash University, Melbourne, Australia
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Introduction: Assistive technologies are becoming more common in total hip replacement (THR) procedures, improving surgeons’ abilities to achieve target implant orientations. These systems can be large, absorbing limited space in the operating theatre, and they can add complexity to surgery.
Materials and Methods: We developed a small footprint prototype system that can assist in the accurate placement of implant components using augmented reality (AR) technology into preoperatively planned positions. This technology augments the 3D pelvis and the cup in its target position and displays the real-time position of instruments.
The accuracy of the developed prototype system was assessed through a cadaveric study, comparing the achieved implant positions to the preoperative target. All cadavers received preoperative 3D planning to identify the target cup position and orientation. Cadaveric surgeries were completed using the AR system to achieve the target cup placement. Postoperative computed tomography (CT) was used to measure the achieved component position for each hip.
Results: The mean absolute deviation (range) from target acetabular placement to the achieved acetabular placement was 2.9° (-8.7 to 3.3°), 3.0° (-5.7 to 7°) and 1.6mm (-1.2 to 3.5mm) for inclination, anteversion, and depth, respectively. Sixty-six percent of results were within +/-5° of the preoperative target orientation.
Conclusion: We present a cadaver validation study on a small footprint prototype system using augmented reality to enable accurate cup placement and provide additional information intraoperatively. Our results are comparable with reported results for image-based navigation from the literature.
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