Surgical Technology International
43rd Edition
December 2023 - ISSN:1090-3941
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A New Hinge Prosthesis Offers Ease of Use and the Ability to Retain the Revision Tibial Baseplate
Emily L. Hampp, PhD, Frank LoPiccolo, BSE, Shilpa Donde, MS, Kerianne Coulon, M. Eng, Sophie Hatcher, BS, Sarah Mastrandrea, BS, Caroline Weinberg, BMS, Joint Replacement, Stryker, Mahwah, New Jersey, Daniel Hameed, MD, Afshin Anoushiravani, MD, Jeremy A. Dubin, BA, Michael A. Mont, MD, Sinai Hospital of Baltimore, Baltimore, Maryland
1746
Total knee arthroplasty (TKA) is a widely practiced surgical procedure, with its efficacy underscored by the increasing number of patients benefiting from it. As primary TKAs rise, the orthopaedic community must prepare for a surge in complex primary and revision knee arthroplasties in the future. While most revisions use non-constrained or semi-constrained prostheses, certain scenarios require a fully constrained (hinge) prosthesis to address major ligamentous and/or bone loss. Over time, hinge designs have evolved, but outcomes with these designs have been mixed. To help address challenges seen with some earlier designs, a new modular revision solution has been designed for both primary and revision surgeries. This system has a new revision baseplate that has compatibilities with varying distal femoral components and introduces an enhanced hinge mechanism. This paper aims to explore the evolution of hinge designs, elaborate on the surgical workflows and intended compatibilities of this new revision hinge system in six different scenarios, and discuss its various potential advantages.
Predictors of Readmission and Reoperation Following Shoulder Arthroplasty in Patients Under 45 Years of Age
Luke C. Zappia, BS, Austen D. Katz, MD, Nicholas Sgaglione, MD, Northwell Health Long Island Jewish Medical Center, New Hyde Park, NY, Junho Song, MD, Mount Sinai Hospital, New York, NY
1688
Background: The use of shoulder arthroplasty has increased among all age groups, albeit most prominently in older patients. While previous studies have investigated predictors of short-term readmission and reoperation in the general population, there is a paucity of literature available on these in patients under 45 years of age. This study aimed to identify the predictors of 30-day readmission and reoperation following shoulder arthroplasty in patients under 45 years of age.
Methods: A retrospective query in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2019 was used to identify patients who underwent primary reverse and anatomic total shoulder arthroplasty and hemiarthroplasty. Multivariate logistic regression was used to identify predictors of 30-day readmission and reoperation.
Results: A total of 530 patients were included. Multivariate regression revealed that Black race and Hispanic ethnicity were independent predictors of readmission. Functional dependence, hypertension requiring medication, and prolonged length of stay predicted reoperation. Finally, low hematocrit and prolonged length of stay predicted morbidity.
Discussion: Identifying and accounting for these risk factors for poor outcomes may help improve perioperative risk stratification. As a result, these findings have the potential to reduce healthcare costs associated with readmission and reoperation following shoulder arthroplasty in young patients. Our results also highlight the underlying disparities in healthcare outcomes among racial and ethnic groups that must be considered.
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What Drives the Material Costs of Total Knee Arthroplasty in the Operating Room?
Hannah L. Simmons, BS, Alison K. Klika, MSm Ignacio Pasqualini, MDm Pedro J. Rullán, MD, Robert M. Molloy, MD, Matthew E. Deren, MD, Joshua L. Tidd, BS, Nicolas S. Piuzzi, MD, Cleveland Clinic Foundation, Cleveland, Ohio
1703
Introduction: Approximately one-third of US healthcare spending is related to surgical care. Optimizing operating room (OR) spending is crucial, specifically for high-volume procedures like total knee arthroplasty (TKA). Therefore, the primary objective was to identify leading material drivers of cost for TKA procedures within the OR.
Materials and Methods: Patients who underwent a primary, elective TKA from 2018 to 2019 were included (n=8,672). Intraoperative cost details for each TKA patient were captured from the Vizient Clinical Database Resource Manager (CDB/RM) data. Each cost type was categorized into (1) implant, (2) disposables, (3) wound care, and (4) miscellaneous.
Results: 7,124 patients undergoing primary TKA were included. Implant-related costs accounted for 87.3% of cost, disposable materials covered 10.7%, and wound care products took 2%. The leading subcategories of implant costs were primary prosthetics (85.1%), revision prosthetics (9.9%), cement (2.8%), and implant instruments (1.7%). Within disposables, surgical products accounted for 81.3% of the cost, patient care products for 8.9%, medical apparel for 7.9%, and electrolytes for 1.8%. For an average individual TKA procedure, 86.4% (±4.4) of total cost went towards the implant, 10.7% (±3.4) towards disposable materials, and 1.6% (±1.4) to wound care products. Within the implant category, 92.5% (± 12.8) of costs were associated with primary implants, 13.3% (± 6.9) with instruments, and 2.5% (± 2.8) with cement.
Conclusions: The primary operative material expense category was costs associated with the TKA prosthesis and its fixation followed by disposable materials. A large amount of variation exists in the percent of the total cost for a given TKA procedure that can be attributed to each category.
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Robotic-Arm Assisted Total Hip Arthroplasty: Workflow Optimization and Operative Times
Joseph Nessler, MD, Carla Stephanie, RN, St. Cloud Surgical Center, St. Cloud, MN, Kevin Barga, RN,MS, Andrea Coppolecchia,MPH, Stryker,Mahwah, NJ
1708
Robotic-arm assisted total hip arthroplasty (RATHA) has been demonstrated to offer several benefits, such as increased accuracy in the placement of implants, improved patient outcomes and reduced complications such as dislocations in total hip arthroplasty. However, the potential increase in surgical time may sway some practitioners to hesitate adopting this technology, despite its benefits. Studies of RATHA learning curves have demonstrated that time neutrality can be achieved, but do not describe an efficient workflow. This paper lays out a process to achieve an optimal RATHA workflow and efficiencies in an ambulatory surgery center and presents timing data from 105 cases. We demonstrate that the learning curve for implementing RATHA can be navigated such that providers can offer the clinical benefits of RATHA to their patients without increasing operative or overall perioperative patient time.
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Robotic Total Knee Arthroplasty is Associated with Earlier Return of Postoperative Range of Motion
Travis R. Weiner, BS, Emily D. Ferreri, BS, Nana O. Sarpong, MD, Associate Professor, Roshan P. Shah, MD, Associate Professor, H. John Cooper, MD, Associate Professor, Columbia University Medical Center, New York, New York
1724
Introduction: Postoperative range of motion (ROM) is an important measure for the functional outcome and overall success after total knee arthroplasty (TKA). While robotic knee systems have been shown to reduce pain and improve early function, the return of postoperative ROM specifically has not been adequately studied. The purpose of this study was to compare postoperative ROM in robotic and conventional TKA. We hypothesized that robotic TKA leads to an improvement in postoperative ROM.
Materials and Methods: A retrospective cohort study of 674 primary TKAs by a single surgeon between January 2018 and February 2023 was completed. Patients that did not have both a two-week follow up and eight-week follow up were excluded. Revision/conversion TKAs were excluded. The population was divided into two cohorts based on technique utilized: robotic versus conventional. Preoperative extension/flexion data, postoperative extension/flexion data at two-week and eight-week follow ups, and manipulation under anesthesia data were collected. ROM was defined as flexion minus extension. Chi-square tests were used to examine for differences between categorical variables and t-tests for continuous variables.
Results: A total of 307 robotic and 265 conventional knees were included. There were no differences in demographics, mean follow up, or preoperative ROM between groups. The robotic group had significantly more flexion (99.20° vs. 96.98°; p=0.034) and ROM (97.81° vs. 95.56°; p=0.047) at the two-week follow up. The loss in ROM at the two-week follow up from preoperative ROM was significantly less for the robotic group (-11.21° vs. -14.16°; p=0.031). There were no significant differences in extension at either follow up, in flexion at the eight-week follow up, or in ROM at the eight-week follow up.
Conclusion: Robotic TKA leads to an improvement in postoperative flexion and ROM when compared to preoperative ROM at two-week follow up. These findings could partially explain the quicker recovery associated with robotic TKA.
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Using Software to Implant Orthopaedic Hardware: Surgeon Intraoperative Confidence Increased with Latest Technological Updates
Melanie Caba, MS, Laura Scholl, MS, Alexandra Valentino-Pfeil, MBA, Emily Hampp, PhD, Stryker Orthopaedics, Mahwah, New Jersey, Nipun Sodhi, MD, Long Island Jewish Medical Center, New York, New York, Jeremy Dubin, BA, Daniel Hameed, MD, Michael A. Mont, MD, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
1716
Background: Robotic-assisted total knee arthroplasty (TKA) has been associated with improved accuracy and precision of implant placement, protection of soft tissue, and improved patient-reported postoperative outcomes when compared to manual TKA techniques. Previous studies have highlighted the importance of surgical confidence throughout the learning curve when adopting robotic-assisted platforms. The purpose of this study was to evaluate the confidence and efficiencies of surgeons when utilizing computed tomography (CT)-based robotic TKA technology.
Materials and Methods: A cross-sectional, questionnaire-based study was conducted with 20 arthroplasty-trained surgeons with prior experience in both manual TKA and robotic-assisted TKA techniques. The surgeons completed an initial learning period, with new software, during various stages of their experience. The new TKA software upgrade builds on the prior software version with new features. A Net Promoter Score (NPS), the measurement of a respondent’s likelihood to recommend a product or service to others, was used during the analysis of survey questions. A NPS over 50 indicates a positive score.
Results: When compared to manual TKA techniques, 95% of surgeons reported that their overall intraoperative confidence increased with the new software upgrade for CT-based robotic technology and had an average rating of 8.9 out of 10 for their intraoperative confidence with the new software upgrade. Additionally, 100% of surgeons reported that they were more confident when performing intraoperative implant adjustments with the new software upgrade when compared to manual TKA. Surgeons determined that the overall use of the new software upgrade was intuitive (8.4 of 10 average rating) and were satisfied with the overall use of the new software upgrade (9 of 10 average rating). Also, surgeons reported that they would recommend the new software upgrade for CT-based robotic technology to colleagues (NPS of 85), as well as being used as a research tool (NPS of 85) or for a training and education tool in a fellowship program (NPS of 90).
Conclusion: As new technology continues to enter the field of orthopedics, it is important to ensure upgrades and advancements continue to serve surgeons and provide efficiencies in the operating room. For established robotic surgeons, the new robotic technology assessed in this study provided increased confidence when compared to manual TKA. Based on these results, the new software upgrade demonstrated value during various stages of a TKA procedure and is highly recommended for use by others in the field of orthopedics.
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Building a Multidisciplinary Care Pathway Supported by a Surgical Approach to Local Bone Formation
Antoni Fraguas, MD,
Fernando Torres, MD,
Artro Esport, Barcelona, Spain,
Francisco Castro, MD,
Teknon Medical Center, Barcelona, Spain,
Ernesto Guerra, MD,
Hospital de la Vall d’Hebron, Artro Esport, Barcelona, Spain,
Jorge Nuñez, MD, PhD
Hospital Mutua de Terrassa, Artro Esport, Barcelona, Spain
1713
Osteoporosis is the most common disease of bone mineral metabolism. In Spain, it affects approximately 3 million people, of whom 80% are females and 20% are males. Despite the advances that have been made in this field, we continue to witness alarming levels of fragility hip fractures. In 2010, the cost of osteoporosis in the European Union was estimated to be 37,000 million euros, which included the costs for the treatment of incident fractures (66%), pharmacological prevention (5%), and long-term fracture care (29%).
A multidisciplinary care pathway supported by a surgical approach to local bone formation is needed. Recently, the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) included in their treatment guidelines a local osteo-enhancement procedure (LOEP) as a treatment option.
In the Ossure™ LOEP technique (AgNovos Healthcare USA, LLC, Rockville, MD), a calcium-based triphasic osteoconductive implant material (AGN1), which has been shown to increase bone mineral density (BMD) and proximal femoral strength, is introduced percutaneously in the femoral neck and intertrochanteric region. Basically, the procedure consists of three percutaneous steps: prepare, clean, and fill the cavity with AGN1. It can be carried out with sedation and local anaesthesia or spinal anaesthesia. This report presents a clinical case and discusses how to select patients who could potentially benefit from this technique.
Does Preoperative Statin Exposure Reduce Prosthetic Joint Infections and Revisions Following Total Joint Arthroplasty?
Oliver C. Sax, DO, MS, Zhongming Chen, MD, Sandeep S. Bains, MD, Danielle A. Jacobstein, Jeremy A. Dubin, BA, Daniel Hameed, MD, Mallory C. Moore, BS, Michael A. Mont, MD, James Nace, DO, Ronald E. Delanois, MD, Orthopaedic Attending, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, MD
1717
Introduction: The pleiotropic effects of statins extend beyond managing cardiovascular health and are suggested to modulate Staphylococcus aureus biofilm formation with prosthetic joint infection (PJI) reduction. However, a large analysis of statin use prior to total joint arthroplasty (TJA) to determine infection and revision risk is lacking. We specifically evaluated: 90-day to two-year (1) prosthetic joint infection (PJIs); (2) revisions; and (3) respective risk factors.
Materials and Methods: We queried a national, all-payer database for patients undergoing either TKA or THA between 2010–2020. Chronic statin exposure was defined as >3 prescriptions filled within one-year prior to TJA (statin users). A control cohort of patients undergoing TJA without history of statin use prior was identified (statin naïve). Cohorts were matched 1:1 based on demographics and comorbidities (TKA: n=579,136; THA: n=202,092). Multivariate logistic regression was performed to evaluate risk factors for PJIs and revisions.
Results: Among TKA recipients, statin users had lower incidence of PJIs at one year (0.36 vs. 0.39%) to two years (0.45 vs. 0.49%) compared to the statin naïve (all, p≤0.007). Similarly, statin users had lower incidence of one- to two-year revisions (all, p≤0.048). Among THA recipients, statin users had lower incidence of PJIs at 90 days (0.37 vs. 0.45%) to two years (2% vs. 2.14%) (all, p<0.001). Similar trends were observed for 90-day to two-year revisions (all, p≤0.022). Statin use was independently associated with decreased odds of PJIs and revisions by one year.
Conclusions: Statin use is associated with a reduced risk of PJIs and revisions from one to two years following TJA. It may be worthwhile to ensure patients take statin therapy if indicated for previously established cardiovascular guidelines.
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Mako® Robotic-Arm Assisted Total Hip Arthroplasty: Avoiding Impingement with Updated THA Software
Robert Marchand, MD, South County Orthopaedics, Wakefield, Rhode Island , Devin Olsen, DO, Nate Angerett, DO, Michael A. Mont, MD, Daniel Hameed, MD, Sinai Hospital of Baltimore, Baltimore, Maryland, Craig Shul, MD, Tyler Edmond, MD, University of Maryland Orthopaedics, Baltimore, Maryland
1719
The use of robotic-assisted total hip arthroplasty and three-dimensional computed tomography scan-based templating has become increasingly popular over the last 10 years. However, proper planning and execution are vital to producing optimal patient outcomes. In order to achieve these outcomes, the robotic-assisted system requires training, familiarity, and experience. The goal of this article is to provide clear and condensed examples of preoperative planning, as well as adjustments that one can make to avoid impingement. The surgical technique for robotic-assisted total hip arthroplasty is also briefly discussed. Examples will be given using the latest computed tomography (CT) scan-based robotic platform for osteoarthritic hips, with specific examples of various cases of impingement that might be encountered by the surgeon and how to ultimately avoid this problem when performing the arthroplasty. This article, through case histories, will discuss the various principles and adjustments that can be made to place components in the ideal location based on individual anatomy.
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Recent Advances in Rib Plating
Ryan Desrochers, MD, Yuen-Joyce Liu, MD, Andrew R. Doben, MD, Associate Professor, Saint Francis Hospital, Hartford, CT, SarahAnn S. Whitbeck, Chest Wall Injury Society, Salt Lake City, UT, Susan Kartiko, MD, PhD , Assistant Professor, The George Washington University SMHS, Washington, DC , Thomas W. White, MD, Adjunct Professor, Intermountain Medical Center, Murray, UT
1726
Rib fractures are a common injury in blunt trauma and are associated with high morbidity and mortality. Recent advances in surgical stabilization of rib fractures (SSRF) have led to better patient outcomes for those with highly unstable complex rib fractures, as well as those with less severe injuries. This result has been due in part to the expansion of indications for repair, as well as the development of new hardware systems to address a variety of fracture patterns and injuries. This joint advancement of operator techniques, outcomes research, and industry development has brought SSRF to the forefront of rib fracture management and challenged non-operative paradigms. The future of repair is now shifting focus, as surgeons develop minimally invasive approaches and challenge manufacturers to develop new systems, instruments, and materials to address increasingly complex fracture patterns. These expansions promise to make SSRF an increasingly effective form of management for traumatic rib fractures.
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Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation
Nayeem Baksh, BS, Qais Naziri, MD, MBA, Downstate Medical Center (SUNY), Brooklyn, New York, Scott Douglas, MD, Jeremy Dubin, BA, Sandeep S. Bains, MD, DC, MBA, Daniel Hameed, MD, Mallory C. Moore, BS, Michael A. Mont, MD, John V. Ingari, MD2, Sinai Hospital of Baltimore, Baltimore, Maryland
1729
Introduction: In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures.
Materials and Methods: For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a “proximal humerus fracture” diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses.
Results: We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05).
Conclusion: The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.
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Adipose Tissue Stem Cells for Knee Arthritis and Cartilage Lesions: A Three-Year Follow Up
Dimitrios Tsoukas, MD, MSC, Adj. Professor, Christos Simos, MD, MITERA Hospital, Athens, Greece, Vasilliki Kalodimou, MD, Professor of Cytometry, IASO Maternity and Research Hospital, Athens Greece
1742
Introduction: The purpose of this research article is to evaluate the efficacy and the safety of injections of stromal vascular fraction (SVF), obtained with mini-lipoaspiration of fat tissue for knee osteoarthritis and cartilage lesions.
Materials and Methods: Between January 2018 and February 2021, a total of 76 patients (45 females and 31 males, mean age 64 years; range 53–75 years, body mass index [BMI] no more than 30%, with symptomatic primary osteoarthritis of the knee, without previous arthroscopic intervention) underwent a local tumescent lipoaspiration procedure of 60–80cc of fat tissue from the abdomen. SVF was obtained after centrifugation according to the AdiPrep® Adipose Transfer System (Harvest-Terumo, Plymouth, Massachusetts) technique. The final product was checked with flow cytometry for absolute numbers, vitality, and the cluster of differentiation (CD) population. It was injected intraarticularly into the patients knees. Patients were divided in two groups: Group 1 had patients with knee osteoarthritis Kellgren-Lawrence grade early 4 and Group 2 with osteoarthritis K-L grade 2-3. The International Knee Documentation Committee (IKCD) and Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaires were used to evaluate clinical effects and measure patient’s subjective assessment of pain, joint mobility, and physical disability before the injections. They were repeated at six months, one year, two years, and three years post injections. Knee cartilage lesions patients were divided in two subgroups: Group A (11 patients with OA K-L grade 2-3 and Outerbridge cartilage lesions grade 2-3) and Group B (7 patients with OA K-L grade early 4 and cartilage lesions Outerbridge grade late 3 to early 4) were estimated with quantitive analysis of magnetic resonance imaging (MRI) at one, two, and three years post injections.
Results: The average IKDC score in Group 1 was 45.9, 63.2, 62.4, 60, and 52. The KOOS score of the same group was 53, 79, 72, 69, and 62 at the end of the third year. At baseline, the average total IKDC score in Group 2 was 48.3, at 6 months 78.2, at one year 77, at two years 70.4, and at three years 61. The KOOS score of this group was 57, 84, 86, 79, and 69 at three years, respectively. For the patients with cartilage lesions, Group A presented lesser volume mean numbers of the lesion: 74% at the end of the first year post injection, 61% at the second, and 52% at the end of the third year with two out of seven patients in the group. The rest had no significant difference. Lesser volume mean number of the lesions in Group B was 85–88%, 70%, and 61% at the end of the third year in 5 out of 11 patients in the group. The rest had no significant difference.
Conclusion: Adipose-derivedSVF, injected intraarticularly in arthritic knees, seems to provide good to excellent clinical results for three years and radiological results for cartilage lesions for two years post injections. All patients were satisfied with this treatment with reduction in pain and better joint mobility, especially after two to three months and up to three years. No serious side effects or complications were reported.
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The Use of Plant-Based Polysaccharide (PSP) Agents May Improve Early Outcomes Following Total Knee Arthroplasty—A Proof-of-Concept Study
Michael Ast, MD, Sean McMillan, DO, Virtua Health System, Cherry Hill, New Jersey, Emile-Victor Kuyl, BS, Dan Devine, BA, David Mayman, MD, Jason Blevins, MD, Brian Chalmers, MD, Hospital for Special Surgery, New York, New York, Elizabeth Ford, DO, Mohamed Albana, DO, Inspira Health Network, Vineland, New Jersey
1733
Our study sought to investigate the effects of a topical plant-based polysaccharide (PSP) as an adjunctive hemostat to minimize blood loss and improve early clinical outcomes in patients undergoing primary TKA. In this multi-center and randomized proof-of-concept study, 61 patients undergoing TKA were randomly assigned to one of two groups: A) intraoperative utilization of PSP (n=31) or B) no intervention (n=30). The primary outcomes were blood loss and change in hemoglobin, measured preoperatively and 24 hours postoperatively. Other endpoints included postoperative complications, Knee Society Score (KSS), knee range of motion (ROM), and thigh circumference. There was no difference in postoperative change of hemoglobin or calculated blood loss between the PSP and control groups. The PSP group achieved elevated flexion at two weeks (100.1° vs. 86.6°, p<0.05) and better change in KSS from preop to 90 days (29.5 vs. 22.4, p<0.05) than the controls. Some early postoperative outcomes were improved, which suggests a potential benefit of using PSP in primary TKA. However, the clinical significance of these differences warrants further investigation in a larger randomized trial.
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What is the Efficacy of Intra-Articular Platelet-Rich Plasma Injections for , Knee Osteoarthritis in Clinical Practice? A “Real-Life” Prospective Cohort
Leonardo Oliveira, MD, Cleveland Clinic Florida, Weston, Florida, Dominic King, DO, Jason Genin, DO, Anthony Miniaci, MD, Shujaa Khan, MD, George F. Muschler, MD, Ignacio Pasqualini, MD, Pedro Rullán, MD, Melisa Orr, BS, Cleveland Clinic Foundation, Cleveland, Ohio, Evan Peck, MD, Farah Tejpar, MD, Gregory Gilot, MD, Cleveland Clinic Florida, Weston, Florida, Nicolas S. Piuzzi, MD, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
1736
Introduction: Platelet-rich plasma (PRP) injections may improve symptoms in patients suffering from knee osteoarthritis. However, there is a lack of data on its effectiveness in a “real-life” cohort. This multi-site institutional registry study aimed to assess patients’ longitudinal progress after PRP injection for knee osteoarthritis.
Materials and Methods: All patients receiving PRP injections for knee osteoarthritis at a large, integrated tertiary academic center (December 18, 2017 to March 1, 2021) were eligible. A prospective data collection instrument was used to collect patient demographics, procedural information, and patient-reported outcome measures. Overall, 97 patients met the inclusion criteria, and 53 were included in the analysis.
Results: One in four patients (26%) improved on all three Knee Injury and Osteoarthritis Outcome Score subscales: 17% in two subscales and 20% in one subscale, respectively. Overall, 64% of patients improved in at least one patient-reported outcomes measure. At six months post injection, 49% of patients were satisfied.
Conclusion: PRP injection provides positive changes in two out of three patients in different magnitudes and characteristics with careful attention to clinically meaningful differences.
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An External Acetabular Alignment Guide Decreases Positional Variance
Harsh Wadhwa, BS, Shay I. Warren, MD, Kingsley Oladeji, MD, Andrea K. Finlay, PhD, James I. Huddleston, III, MD, Professor, Derek F. Amanatullah, MD, PhD, Associate Professor, Stanford University Medical Center, Stanford, California
1735
Introduction: Certain patient and operative factors limit accurate estimation of acetabular component positioning during total hip arthroplasty (THA). This study aimed to determine whether an intraoperative external alignment guide decreases variance in acetabular component positioning.
Materials and Methods: Adult patients who underwent primary THA from 2014–2018 were reviewed. Exclusion criteria were navigation, robot-assisted surgery, and inflammatory, post-traumatic, or avascular arthritis. One surgeon used an external guide while the second surgeon resected osteophytes and utilized available anatomical landmarks for positioning. Anteversion and inclination, variance, “safe zone” positioning, operative time, and hip instability were assessed. Multivariable regression models were used to examine effects on primary and secondary outcomes.
Results: 409 patients were included, of which 182 underwent component placement with landmarks only. Patients undergoing component placement with landmarks only were younger (p=0.002) and more often smokers (p=0.016). After multivariable risk adjustment, use of the external alignment guide was independently associated with 2.7° higher anteversion (CI: 1.6° to 3.8°) and smaller anteversion variance (-0.3, CI: -0.6 to 0.1) compared to landmarks only. It was independently associated with 3.2° higher inclination (CI: 2.0° to 4.4°), but there was no difference in inclination variance (-0.1, CI: -0.3 to 0.2). The external alignment guide was independently associated with a 14-minute shorter operative time (CI: 9.6 to 18.7) and smaller operative time variance (-0.9, CI: -1.2 to 0.6).
Discussion: Use of anatomical landmarks alone was associated with increased likelihood of safe zone positioning but lower precision and longer operative time. While this study was limited by lack of randomization and its retrospective nature, an acetabular positioner may be preferable to palpable or visible anatomy alone for acetabular component placement.
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Effect of Various Ancillary Operating Room Techniques on Wound Healing Outcomes After Total Knee Arthroplasty
Jeremy A. Dubin, BA, Daniel Hameed, MD, Michael A. Mont, MD, Sandeep S. Bains, MD, DC, MBA, Sinai Hospital of Baltimore, Baltimore, Maryland, Tim Board, MD, Wrightington Hospital, Wigan, United Kingdom Ryan Nunley, MD, Washington University in St. Louis, St. Louis, Missouri
1748
Introduction: The successful management of wound healing after total knee arthroplasty (TKA) depends on several aspects of ancillary intraoperative techniques and surgical variables. Many of these have been evaluated in a few recent reports. The prior reviews studied many aspects of wound healing and, for example, found lower risks of wound complications with barbed sutures compared with interrupted closure with non-barbed sutures, no differences in wound complications between adhesives, subcuticular sutures, staples, glue, or mesh adhesives for the closure of the skin layer, and that mesh adhesives may be associated with faster closing times compared to subcuticular sutures or staples in TKA. However, some topics that can be influenced by the surgeon were not covered in these previous reviews. Namely, the use of deep vein thrombosis (DVT) prophylaxis, tourniquet application, management of intraoperative drains, surgical approach selection, and patellar handling techniques can all potentially influence wound healing. Therefore, in this comprehensive systematic review of the literature, we focused on these five factors that may influence wound healing. Specifically, we evaluated: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the role of tourniquet application on wound closure and potential infection risks; (3) the effects of intraoperative drain usage on wound healing; (4) the influence of different surgical approaches on wound closure and postoperative infection rates; and (5) the effects of varying patellar handling strategies on wound healing and infection rates.
Materials and Methods: A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing auxiliary surgical techniques and their impact on wound healing in total knee arthroplasty (TKA). Relevant terms like “knee,” “arthroplasty,” and “wound healing” refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 24 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in TKA, which included evaluating methodological quality parameters like sample sizes, follow-up durations, and clinical effect measurements. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level.
Results: There were seven reports on DVT prophylaxis that showed no statistically significant differences in wound complications among various treatment methods and medications in patients undergoing total knee arthroplasty (TKA), with wound complication rates ranging from 0.25 to 1%, except that aspirin appeared to have lower wound complications rates in three recent studies than other methods. There were five reports on tourniquet application that showed a generally increased rate of wound complications, but no increase in deep infections. The five reports on intraoperative drain use showed that while there is an increase in total blood loss in the group with drains, ranging from 568ml to 1,856ml, compared to 119ml to 535ml in the no-drain group, there are no significant differences in wound complications, infection rates, or other postoperative outcomes such as swelling, deep vein thrombosis, and range of motion between the drain and no-drain groups. There were three studies on surgical approaches revealing no differences in wound complication rates between the mini-subvastus and medial parapatellar incisions. Also, the surgical variables of patella eversion and anterior tibial translation were only studied in one report.
Conclusion: The current literature highlights the importance of using aspirin when possible for DVT prophylaxis and the possibility that tourniquets may lead to increased superficial wound complications. Drains or surgical approach do not appear to lead to wound problems. Surgical variables, such as patella eversion and anterior tibial translation, need more study.
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Effect of Various Ancillary Operating Room Techniques on Wound Healing,
Outcomes After Total Hip Arthroplasty
Daniel Hameed, MD,
Jeremy A. Dubin, BA,
Sandeep S. Bains, MD, DC, MBA
Michael A. Mont, MD,
Sinai Hospital of Baltimore, Baltimore, Maryland,
Tim Board, MD,
Wrightington Hospital, Wigan, United Kingdom,
Ryan Nunley, MD, Washington University, St Louis, Missouri
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Introduction: The successful management of wound healing following total hip arthroplasty (THA) is multifaceted, relying on various intraoperative techniques and surgical variables. Recent reviews have evaluated many of these factors, including the comparison between mesh-adhesive dressings and other skin closure methods, the closing time of different suture techniques, and the four aspects of closure for THA (deep fascial layer; subdermal layer; intradermal layer). However, previous articles did not cover certain topics that can be directly influenced by the surgeon. Specifically, these include the use of deep vein thrombosis (DVT) prophylaxis, the management of intraoperative drains, and the selection of surgical approaches. Therefore, in this comprehensive systematic review of the literature, we have focused on three factors that may influence wound healing. We evaluated the following: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; (3) the influence of various surgical approaches on wound closure, and postoperative infection rates. By concentrating on these areas, this review aims to provide a more complete understanding of the factors that contribute to successful wound management after THA.
Materials and Methods: A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing surgical variables and techniques, specifically focusing on DVT prophylaxis, intraoperative drain use, and surgical approaches and their impact on wound healing in THA. Relevant terms like “hip,” “arthroplasty,” “wound healing,” “DVT prophylaxis,” and “surgical approaches” refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 13 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in THA, specifically focusing on the three factors outlined in the introduction: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; and (3) the influence of various surgical approaches on wound closure and postoperative infection rates. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level, and aimed to contribute to a more complete understanding of the factors that influence successful wound management after THA.
Results: In studies examining DVT prophylaxis for total knee arthroplasties (TKA), three reports found that both rivaroxaban and enoxaparin had similar wound infection rates at 0.36%. However, one study segment suggested a slightly higher infection rate for rivaroxaban at 0.71% compared to enoxaparin’s 0.49%. Despite this difference, it was not statistically significant (odds ratio [OR] 1.34, 95% confidence interval [CI] 0.46 to 3.86). In recent research, a low dose of aspirin has been observed to yield fewer wound complications when contrasted with other techniques. Five studies on intraoperative drain use revealed mixed outcomes. A total of five studies were identified that evaluated wound complications with drains following THA, comprising two randomized controlled trials (RCTs) and three observational cohort studies, with a combined sample size of 765. Among these, four studies specifically compared the use of closed suction drains to no drains. Half of these studies (two out of four) reported no significant differences in wound complications between the two groups, while the other half presented mixed findings. In surgical approach comparisons by Jin et al., meta-analysis between the direct anterior approach (DAA) and posterolateral approach (PLA) showed no significant difference in complications (OR 0.57, p=0.952). Two studies analyzed bikini incision DAA versus PLA or conventional DAA, indicating comparable outcomes with no significant differences in wound complications between the approaches and no major variations in healing, acute PJI, or dysesthesia when comparing bikini incision DAA to conventional DAA.
Conclusion: Wound healing post THA is a complex process, influenced by various surgical techniques and intraoperative decisions. This systematic review meticulously examined three critical factors: the role of DVT prophylaxis, the implications of intraoperative drain usage, and the impact of different surgical approaches. Our analysis revealed that rivaroxaban and enoxaparin exhibit similar wound infection rates in THA. The decision to use intraoperative drains in the current literature indicates no definite advantage or disadvantage regarding wound problems with the use of closed-suction drainage in THA. In exploring surgical methodologies, the DAA and the PLA showed comparable complication rates. Yet, specific techniques within the DAA category demonstrated variations in delayed wound healing, particularly among obese patients. These findings emphasize the nuanced role of surgical choices in determining wound healing outcomes. As the field of THA continues to evolve, it becomes important for surgeons to be well-informed, ensuring optimal patient outcomes.
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