Probing forces of menisci: what levels are safe for arthroscopic surgery

Purpose To facilitate effective learning, feedback on performance during arthroscopic training is essential. Less attention has been paid to feedback on monitoring safe handling of delicate tissues such as meniscus. The goal is to measure in vitro probing forces of menisci and compare them with a theoretical maximum probing force (TMPF). Method Menisci samples of ten cadavers were mounted on force platforms to measure probing forces up to 20 N in three directions. Nineteen subjects participated: six novices (experience 60 arthroscopies), and three faculty (>250 a year). All had to perform three tasks on each meniscus sample with an arthroscopic probe: push three times on the superior meniscal surface, perform one continuous run on the superior meniscal surface, and push three times on the inferior meniscal surface. The absolute maximum probing force (AMPF) was determined for each condition. A multivariable linear regression analysis was performed to assess the influence of experience on the force magnitude (P < 0.05). AMPFs were compared to the TMPF (estimated to be 8.5 N). Results The AMPF of the push task was on average 2.8 N (standard deviation (SD) of 0.8 N), of the continuous run task 2.5 N (SD 0.9 N), and of the pull task 3.9 N (SD 2.0 N). Significant difference was present between experts and novices (P < 0.05). The AMPFs are in the same order of magnitude as the TMPF. Conclusion The results indicate the necessity of using a safety level for tissue manipulation when training arthroscopy and a value for is magnitude.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

The long-term fate of the hip arthrodesis: does it remain a valid procedure for selected cases in the 21st century?

Even in current orthopaedic practice, some cases are still not suitable candidates for hip replacement and hip fusion remains the only option in these highly selected patients. In this retrospective study we describe the long-term clinical outcome, quality of life and radiological evaluation of all adjacent joints in a cohort of 47 hip fusions. The main objective of our study was to show the long-term effects of a fusion. Thirty patients were analysed after an average of 18.2 years (range 6.2–30.5 years) with a mean SMFA of 31.2 (range 9–70). The VAS for pain for the fused hip was an average 1.9 (range 0–8), for the contralateral hip 2.0 (0–8), for the ipsilateral knee 2.0 (0–8), for the contralateral knee 1.8 (0–8) and for the lower back 3.6 (0–8). Average walking distance was 115 minutes (range 10–unlimited). Although the hip arthrodesis has lost popularity, it still is an option for the young patient with severe hip disorders, while leaving the possibility to perform a THA at a later stage. If the arthrodesis is performed with an optimal alignment of the leg, complaints from the adjacent joints are minimal, even in the long-term, and an acceptable quality of life can be obtained. We believe that in highly selected cases a hip fusion, even in current practice, is still a valid option

Time-Action Analysis (TAA) of the Surgical Technique Implanting the Collum Femoris Preserving (CFP) Hip Arthroplasty. TAASTIC trial Identifying pitfalls during the learning curve of surgeons participating in a subsequent randomized controlled trial (An observational study)

<p>Abstract</p> <p>Background</p> <p>Two types of methods are used to assess learning curves: outcome assessment and process assessment. Outcome measures are usually dichotomous rare events like complication rates and survival or require an extensive follow-up and are therefore often inadequate to monitor individual learning curves. Time-action analysis (TAA) is a tool to objectively determine the level of efficiency of individual steps of a surgical procedure.</p> <p>Methods/Design</p> <p>We are currently using TAA to determine the number of cases needed for surgeons to reach proficiency with a new innovative hip implant prior to initiating a multicentre RCT. By analysing the unedited video recordings of the first 20 procedures of each surgeon the number and duration of the actions needed for a surgeon to achieve his goal and the efficiency of these actions is measured. We constructed a taxonomy or list of actions which together describe the complete surgical procedure. In the taxonomy we categorised the procedure in 5 different Goal Oriented Phases (GOP):</p> <p>1. the incision phase</p> <p>2. the femoral phase</p> <p>3. the acetabulum phase</p> <p>4. the stem phase</p> <p>5. the closure pase</p> <p>Each GOP was subdivided in Goal Oriented Actions (GOA) and each GOA is subdivided in Separate Actions (SA) thereby defining all the necessary actions to complete the procedure. We grouped the SAs into GOAs since it would not be feasible to measure each SA. Using the video recordings, the duration of each GOA was recorded as well as the amount of delay. Delay consists of repetitions, waiting and additional actions. The nett GOA time is the total GOA time – delay and is a representation of the level of difficulty of each procedure. Efficiency is the percentage of nett GOA time during each procedure.</p> <p>Discussion</p> <p>This allows the construction of individual learning curves, assessment of the final skill level for each surgeon and comparison of different surgeons prior to participation in an RCT. We believe an objective and comparable assessment of skill level by process assessment can improve the value of a surgical RCT in situations where a learning curve is expected.</p

Soft tissue damage after minimally invasive THA: A comparison of 5 approaches

Methods 5 surgeons each performed a total hip arthroplasty on 5 fresh frozen cadaver hips, using either a MIS anterior, MIS anterolateral, MIS 2-incision, MIS posterior, or lateral transgluteal approach. Postoperatively, the hips were dissected and muscle damage color-stained. We measured proportional muscle damage relative to the midsubstance cross-sectional surface area (MCSA) using computerized color detection. The integrity of external rotator muscles, nerves, and ligaments was assessed by direct observation. Results None of the other MIS approaches resulted in less gluteus medius muscle damage than the lateral transgluteal approach. However, the MIS anterior approach completely preserved the gluteus medius muscle in 4 cases while partial damage occurred in 1 case. Furthermore, the superior gluteal nerve was transected in 4 cases after a MIS anterolateral approach and in 1 after the lateral transgluteal approach. The lateral femoral cutaneous nerve was transected once after both the MIS anterior approach and the MIS 2-incision approach. Interpretation The MIS anterior approach may preserve the gluteus medius muscle during total hip arthroplasty, but with a risk of damaging the lateral femoral cutaneous nerv

Less Anterior Knee Pain with a Mobile-bearing Prosthesis Compared with a Fixed-bearing Prosthesis

Anterior knee pain is one of the major short-term complaints after TKA. Since the introduction of the mobile-bearing TKA, numerous studies have attempted to confirm the theoretical advantages of a mobile-bearing TKA over a fixed-bearing TKA but most show little or no actual benefits. The concept of self-alignment for the mobile bearing suggests the posterior-stabilized mobile-bearing TKA would provide a lower incidence of anterior knee pain compared with a fixed-bearing TKA. We therefore asked whether the posterior-stabilized mobile-bearing knee would in fact reduce anterior knee pain. We randomized 103 patients scheduled for cemented three-component TKA for osteoarthrosis in a prospective, double-blind clinical trial. With a 1-year followup, more patients experienced persistent anterior knee pain in the posterior-stabilized fixed-bearing group (10 of 53, 18.9%) than in the posterior-stabilized mobile-bearing group (two of 47, 4.3%). No differences were observed for range of motion, visual analog scale for pain, Oxford 12-item questionnaire, SF-36, or the American Knee Society score. The posterior-stabilized mobile-bearing knee therefore seems to provide a short-term advantage compared with the posterior-stabilized fixed-bearing knee

Hoffa Nonunion, Two Cases Treated with Headless Compression Screws

A coronal fracture of the distal femoral condyle is a rare entity and a nonunion even more so. The coronal fractures, also known as Hoffa fracture, more often involve the lateral than the medial condyle. Open reduction and internal fixation are the primary treatment of choice. We describe two cases of nonunion of a Hoffa fracture (one medial and one lateral). Although the nonunion fragment was not attached to any soft tissues in both cases the fragment was noted to be vital both clinically and histologically. After operative treatment, consisting of debridement, compression with use of headless screws, and liberal use of bone graft both nonunions healed. At latest follow-up, both patients had excellent function and reported no or minimal pai

Patient-related and work-related factors play an important role in return to work after total knee arthroplasty: a systematic review

Importance A growing group of patients with a total knee arthroplasty (TKA) are still working at the time of the surgery. The average time to return to work (RTW) is estimated at 3–6 months. There is a large range of time that patients need to RTW. Objective The objective of this review is to systematically identify beneficial and limiting factors that affect RTW after TKA. Evidence review PubMed and Embase were searched systematically to find studies that analysed prognostic factors for RTW in patients undergoing TKA. The following inclusion and exclusion criteria were used: patients with a TKA, studies that reported on RTW after TKA, patients had to be between 18 and 65 years and beneficial or limiting factors affecting RTW were described. Studies were included if written in English, German, French or Dutch. The Quality-in-Prognostic-Studies tool was used for the quality assessment of the included studies. Findings 11 of the 306 primarily identified studies met the inclusion criteria. 7 patient-specific and 11 work-related factors were beneficial for a faster RTW, like being male and having a high job qualification. There were three patient-specific and eight work-related factors that were limiting factors for the RTW, like being female and preoperative sick leave. Conclusions and relevance Patients that are male, have a high sense of urgency to return to work, have a high job qualification, are self-employed, with limited sick leave are those that are most likely for a successful and fast RTW. With the use of these factors, patients can be earlier identified as requiring better guidance preoperative and postoperatively for a more successful RTW. Level of evidence Level II

One stage bilateral total hip arthroplasty, is it safe? A meta-analysis

Controversy has prevailed for many years relating to the safety of one-stage and two-stage total hip arthroplasty (THA) for bilateral disease. We performed a meta-analysis of 1460 studies of which 5 prospective studies met our inclusion criteria. A total of 579 patients had two-stage procedures and 334 had one-stage surgery. The studies showed a low heterogeneity (I-2 =0%) allowing pooling of data. No differences were found in the incidence of major complications (odds ratio 0.72 95% CI: 0.45-1.15). One-stage bilateral THA may therefore be a safe procedur

UvA-DARE (Digital Academic Repository) The long-term fate of the hip arthrodesis: does it remain a valid procedure for selected cases in the 21st century?

The long-term fate of the hip arthrodesis: does it remain a valid procedure for selected cases in the 21st century? Schafroth, M.U.; Blokzijl, R.J.; Haverkamp, D.; Maas, M.; Marti, R.K. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Abstract Even in current orthopaedic practice, some cases are still not suitable candidates for hip replacement and hip fusion remains the only option in these highly selected patients. In this retrospective study we describe the long-term clinical outcome, quality of life and radiological evaluation of all adjacent joints in a cohort of 47 hip fusions. The main objective of our study was to show the long-term effects of a fusion. Thirty patients were analysed after an average of 18.2 years (range 6.2-30.5 years) with a mean SMFA of 31.2 (range 9-70). The VAS for pain for the fused hip was an average 1.9 (range 0-8), for the contralateral hip 2.0 (0-8), for the ipsilateral knee 2.0 (0-8), for the contralateral knee 1.8 (0-8) and for the lower back 3.6 (0-8). Average walking distance was 115 minutes (range 10-unlimited). Although the hip arthrodesis has lost popularity, it still is an option for the young patient with severe hip disorders, while leaving the possibility to perform a THA at a later stage. If the arthrodesis is performed with an optimal alignment of the leg, complaints from the adjacent joints are minimal, even in the long-term, and an acceptable quality of life can be obtained. We believe that in highly selected cases a hip fusion, even in current practice, is still a valid option