Second Generation Patient Specific Total Knees Demonstrate a Higher Manipulation Rate Compared with “Off-the-shelf” Implants

Introduction. Patient specific total knee arthroplasty (TKA) theoreticallyprovides a more accurate fit to the native knee but mayhave difficulty achieving full range of motion (ROM) post-operatively.Post-operative ROM data were compared between patientswho underwent cemented patient-specific cruciate-retaining(PSCR) and standard cemented posterior-stabilized (SPS) TKAs. Methods. PSCR and SPS TKAs that were performed from January2014 to September 2015 by the same surgeon using the same postoperativeprotocols at two selected facilities were reviewed. Twoandsix-week post-operative ROM data were obtained and thenumber of patients with knee flexion less than 110° was recorded. Results. Twenty-one patients in the PSCR group and 57 patientsin the SPS group were included. The percentage of patientswith knee flexion less than 110° was similar in both groups preoperatively(10% vs 14%, p = 0.60) and two-week post-operatively(57% vs 68%, p = 0.35). However, at six-week post-operativelythere was significant difference (29% vs 7%, p = 0.01). Conclusions. These results provide evidence to alert orthopaedicsurgeons when using these patient specific implants versus conventionalTKA methods. Patients whose TKA was performed usingpatient specific cutting guides struggled to obtain 110° of kneeflexion. Close monitoring, aggressive physical therapy, and earlymanipulation are recommended when using patient specific cuttingguides and custom total knee implants. Further evaluation ina larger group of patients is warranted. KS J Med 2016;9(4):88-92

Early Outcomes of Cemented versus Cementless Total Knee Arthroplasty

Introduction. Total knee arthroplasty (TKA) has been provento be very effective for long-term pain relief in the degenerativeknee. Few studies have investigated short-term clinicaland functional outcomes between the cemented and cementlessTKA. The specific aim of this study was to assess the potentialdifference of functional outcomes in the early postoperativeperiod between these two surgical options usingthe Knee Society Score (KSS) and range of motion (ROM). Methods. A total of 164 knees that had undergone TKA by a singlesurgeon at a single institution between 2007 and 2010 were reviewed.Three different TKA prosthetic designs (cruciate retaining(CR), posterior stabilized (PS) and cruciate substituting (CS))were included. Data collection included patient demographics,pre- and post-operative ROM, and pre- and post-operative KSSat each visit (1.5 months, 3 months, and 12 months). Two separateKSS scores were assigned: functional score and clinical score. Results. Sixty-seven knees underwent cemented TKA and 97knees underwent cementless TKA. No significant differencewas recognized in either age or body mass index for thesetwo TKA groups. The cementless group showed a significantearly ROM improvement after 1.5 months post-operative (p <0.05), while the cemented group showed ROM improvementonly after three months post-operative. No significant differencewas detected in terms of KSS between the cemented andcementless TKA groups at each measured time period. Bothgroups showed marked KSS improvement (cemented: 135%,cementless: 125%) after 1.5 months post-operative and theKSS seemed to be stabilized after three months post-operativefor both groups (cemented: p = 0.36; cementless: p = 0.07). Conclusions. There was a significant early ROM improvementfor the cementless TKA group compared to the cementedTKA group, but no statistical significant difference was notedin KSS in the early post-operative period when comparing cementedand cementless TKA groups. The findings provide evidencethat cementless TKA patients can undergo an identicalpost-operative protocol to cemented TKA, without concernsabout implant stability or function. KS J Med 2016;9(4):93-98

The Cost of Routine Follow-Up in Total Joint Arthroplasty and the Influence of These Visits on Treatment Plans

Introduction. Many physicians recommend annual or biennial visitsafter total hip and knee arthroplasty (THA and TKA). This studysought to establish the cost of a post-operative visit to both the healthcare system and patient and identify if these visits altered patientmanagement. Methods. A prospective cohort study was conducted using patientspresenting for follow-up after THA or TKA from April throughDecember 2016. All surgeries were performed by a single orthopaedicsurgeon in Wichita, Kansas. All eligible subjects that met the inclusioncriteria received and completed a questionnaire about the personalcost of the visit and their assessment of their function and outcomeafter total joint arthroplasty. The physician also completed a questionnairethat examined the cost of the visit to the health care systemand whether the clinical or radiographic findings altered patient management. Results. Fifty-six patients participated with an average length of follow-up of 4.5 ± 4.1 years since surgery. The average patient cost was$135.20 ±$190.53 (range, $1.65 -$995.88), and the average visit timefor the patient was 3.9 ± 2.9 hours. Eighty percent of patients reportedno pain during the clinic encounter, and 11% reported loss of function.Eighty-four percent thought the visit was necessary. Physician timefor each visit lasted 12.9 ± 3.7 minutes (range, 10 - 20 minutes). Only9% of patient encounters resulted in an alteration in patient management.This occurred at an average follow-up time of 3.6 ± 1.8 yearsafter the index procedure. The average cost of each visit to the healthcare system at large was $117.31 ± 60.53 (range,$93.90 - $428.28). Conclusions. The findings of this study advise total joint patients andorthopaedic surgeons regarding the cost of routine post-operativeappointments and whether these visits alter patient management.The majority of the routine follow-up visits after THA and TKA didnot result in an alteration in patient management, but added substantialcost to the health care system. Kans J Med 2018;11(3):59-66

Bilateral Pectoralis Major Tendon Rupture While Performing Intermediate Level Bench Press

Simultaneous bilateral pectoralis major (PM) tendon rupture is a rare injury. To our knowledge, there have been only three previously reported cases of this type of injury.1–3 These patients sustained the injury while attempting a 360° turn on gymnastic rings,1 bench-pressing a heavier-than-normal load without an appropriate warm-up period,2 and performing dips on wide-grip parallel bars.3 We present a case of a patient who sustained simultaneous bilateral PM tendon ruptures while performing intermediate level bench-pressing with an appropriate warm-up period

Bone Health Improvement Protocol

Introduction. Metabolic bone disease is a malady that causessignificant morbidity and mortality to a patient who has sustaineda fragility fracture. There is currently no protocol toprevent secondary fragility fracture at our institution. The objectiveof this study was to create an appropriate protocol forimplementing clinical pathways for physicians to diagnose andtreat osteoporosis and fragility fractures by educating patients. Methods. A multidisciplinary team created an appropriateprotocol that could be implemented in an inpatient setting.A thorough literature review was conducted to evaluatepotential barriers and efficacious methods of protocol design. Results. A bone health improvement protocol was developed.Any patient over the age of 50 who sustains a fracture from lowenergy trauma, such as a fall from standing or less, should beconsidered to place into this protocol. These patients receivededucation on metabolic bone disease, a prescription for highdose vitamin D therapy, and laboratory testing to determinethe etiology of their metabolic bone disease. Continuity of careof these patients with their primary care provider was providedfor further management of their metabolic bone disease andevaluation of their disease after discharged from the hospital. Conclusion. Comprehensive secondary prevention should consistof osteoporosis assessment and treatment together with afall risk assessment. With this protocol, secondary fragility fracturespotentially could be prevented. KS J Med 2017;10(3):62-66

Intra-Operative Experience using Magnetic Resonance Imaging (MRI) Based Patient Specific Cutting Guides during Total Knee Arthroplasty

Background. The incidence of malalignment in total knee arthroplasty(TKA) using conventional instrument has beenreported as high as 25%. A relatively new TKA system involvesthe use of a preoperative magnetic resonance image(MRI) to obtain accurate implant placement more consistently.For broad acceptance of this new technique, it iscrucial to analyze the initial intra-operative experience. Thespecific aim of this study was to evaluate the initial intra-operativeexperience of a single surgeon using this new technique. Methods. A total of 15 knees (12 patients: 6 female and 6male) were reviewed from TKA procedures using the selectedmanufacturer’s patient specific cutting guides between January2011 and April 2013 at a single institution. Patient demographicand specific parameters and intra-operative alterationsof component positioning were recorded and evaluated.Results. The preoperative plan was able to predict correctly thesize of the implanted femoral component in 87% (n = 13) andtibial component in 80% (n = 12) of the cases. However, 60% (n= 9) of cases required additional intra-operative corrections onfemoral resection, and 73% (n = 11) required an additional 2 - 4mm correction on the tibial proximal resection. Twenty percent(n = 3) required additional tibial varus/valgus correction, butthere were no tibial slope corrections for any of the 15 cases. Conclusions. The initial intra-operative experience of a singlesurgeon using current patient specific cutting guides for a selectedmanufacturer to align femoral and tibial components duringTKA has raised some concerns. We agreed with previous studiesthat caution should be taken when using patient specific cuttingguides without supportive data. The findings of this study providedadditional evidence to contest the accuracy of patient specificcutting guides with respect to the initial experience of an orthopaedicsurgeon who is trained in total joint replacement. Theresults provided more evidence to assist orthopaedic surgeonsin the decision of whether to use these patient specific systemsversus conventional TKA methods. KS J Med 2016;9(2):22-26

Reliability of Hallux Rigidus Radiographic Grading System

Introduction. The purpose of this study was to determine the inter- and intra-observer reliability of a clinical radiographic scale for hallux rigidus. Methods. A total of 80 patients were retrospectively selected from the patient population of two foot and ankle orthopaedic surgeons. Each corresponding series of radiographic images (weight-bearing anteroposterior, weight-bearing lateral, and oblique of the foot) was randomized and evaluated. Re-randomization was performed and the corresponding radiograph images re-numbered. Four orthopaedic foot and ankle surgeons graded each patient, and each rater reclassified the re-randomized radiographic images three weeks later. Results. Sixty-one out of 80 patients (76%) were included in this study. For intra-observer reliability, most of the raters showed “excellent” agreement except one rater had a “substantial” agreement. For inter-observer reliability, only 14 out of 61 cases (23%) showed total agreement between the eight readings from the four surgeons, and 11 out of the 14 cases (79%) were grade 3 hallux rigidus. One of the raters had a tendency to grade at a higher grade resulting in poorer agreement. If this rater was excluded, the results demonstrated a “substantial” agreement by using this classification. Conclusion. The hallux rigidus radiographic grading system should be used with caution. Although there is an “excellent” level of intra-observer agreement, there is only “moderate” to “substantial” level of inter-observer reliability

Comparing the Influence of Different Overhand/Underhand Stacking Combinations of Reversing Half-Hitches on Alternating Posts on Arthroscopic Knot Security

Introduction Previous literature demonstrated the importanceof stacking at least three reversing half-hitches on alternating posts(RHAPs) following arthroscopic knot placement. However, RHAPsconstruction involves looping the suture in either an “overhand” or an“underhand” manner as it relates to the post, which may affect knotsecurity. This study investigated the presently unidentified influenceof different stacking combinations of three RHAPs and suture materialon arthroscopic knot security. Methods Four different RHAPs stacking combinations were tiedwith three different suture materials. Ten knots of each configurationwere tied using each suture material, resulting in 120 evaluated knots.A single load-to-failure test was performed. The mode of failure andmean ultimate clinical failure load were recorded. Results Different overhand/underhand stacking combinations ofthree RHAPs had a statistically significant effect on arthroscopicknot strength and security; however, all combinations surpassed theminimum ultimate clinical failure threshold. Knots constructed witheither Force Fiber® or braided fishing line had mean ultimate clinicalfailure loads of greater than 200 N and most commonly failed due tosuture material breakage (100%, 60 - 80% respectively). Conversely,FiberWire® demonstrated lower mean ultimate clinical failure loadsand had a higher incidence of elongated but intact failure (60 - 90%). Conclusion Different overhand/underhand stacking combinationsof three RHAPs yielded an arthroscopic knot capable of secure tissuefixation. A significant effect was observed for suture materials on theknot strength. This study increases our understanding of suitableRHAPs construction following arthroscopic knot placement that canlead to improving the ultimate clinical failure loads of constructedarthroscopic knots observed between orthopedic surgeons

Outcomes in Combined Anterior and Posterior Fusion for 3- and 4-Level Degenerative Lumbar Disc Disease

Introduction. This study reported the clinical and functionaloutcomes in a consecutive series of patients with3- or 4-level degenerative disc disease (DDD) betweenvertebral levels L2 to S1, who were treated with combinedanterior lumbar interbody fusion (ALIF) and posteriorspinal fusion at one-year and two-year follow-ups. Methods. A retrospective chart review was performed on allpatients who underwent long segment fusion for DDD by asingle surgeon between August 2002 and January 2012. Fiftyfivepatients were identified and 32 had complete charts for review(14 had one-year follow-up and 18 two-year follow-up).In addition to demographic data, disability (Oswestry DisabilityIndex, ODI), pain level (Visual Analog Scale, VAS), andflexion-extension range-of-motion were measured pre- andpost-operatively. Operative data also were collected, includingoperative time, blood loss, surgical implants used, surgicalapproach, operative levels treated, and complications.Results. Both VAS and ODI improved significantly postoperatively.The average VAS score improved from 6.5 ± 1.5(range: 4 - 9) to 4.4 ± 1.7 (range: 2 - 7) for one-year follow-up,and 7.0 ± 1.8 (range: 4 - 10) to 4.4 ± 2.6 (range: 1 - 9) for twoyearfollow-up. For one-year follow-up, the average ODI scoreimproved from 53 ± 19% (range: 18 - 70%) to 37 ± 17% (range:12 - 64%), and for two-year follow-up, the average improvedfrom 53 ± 18% (range: 18 - 80%) to 31 ± 24% (range: 2 - 92%).The level of improvement in pain and function was similar topreviously published data for 1- and 2-level fusions, but overallpain and function scores were worse in this study group. Conclusions. Arthrodesis for 3- and 4-level DDD is, on average,a successful surgery that shows clinically significantimprovements in function and pain similar to fusionfor 1- and 2-levels with low rates of re-operation. Patientswith involvement of 3- or 4-levels have higher disabilityand pain both pre- and post-operatively compared to shorterfusion level involvement. KS J Med 2016;9(3):50-53