Revising Substantial Leg Length Discrepancy in Total Hip Arthroplasty Using Computer-assisted Navigated Systems: A Case Series of Three Patients.

One of the primary challenges of total hip arthroplasty (THA) is equalizing the limb lengths to re-establishing normal hip biomechanics. Post-operative leg length discrepancies (LLD) lead to patient dissatisfaction and are a main source of orthopedic malpractice cases. The aim of this case series was to document three cases of substantial LLD that were corrected during THA with the assistance of an imageless computer navigation system. Medical records were reviewed for history and radiographs were consulted. All patients in this series presented with complaints related to hip fractures and reported a significant lengthening of leg length following THA. No surgical complications of adverse events were reported. In these cases, imageless navigation provided intraoperative measurements of leg length which allowed for enhanced accuracy of component placement and improved outcomes following surgery.

Alignment and Balance Methods in Total Knee Arthroplasty.

Total knee arthroplasty is one of the most commonly performed orthopaedic surgical procedures in the United States. Primary concepts in the surgical technique include restoring limb alignment and soft-tissue balance about the knee. Currently, traditional mechanical alignment concepts that focus on restoring neutral limb alignment have been challenged by the principle of kinematic alignment. In addition to these recent philosophical challenges, new technologies have been introduced to help the surgeon more accurately achieve optimal limb alignment and soft-tissue balance.

Femoral stem size mismatch in women undergoing total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is a highly successful surgery with a high prevalence in women. Women have been noted to have smaller proximal femoral anatomy and decreased bone strength compared to males. The goal of our study was to define the size discrepancy in femoral stem implants between men and women using a metaphyseal fitting single taper stem. METHODS: We retrospectively reviewed the THA's performed by a single surgeon over the previous two years. Data was extracted from operative reports regarding stem size, neck length and offset, and conversion to a different type of stem. This data was reviewed with confidence intervals and a t-test was performed for independent samples with a p < 0.05 being determined significant. RESULTS: We analyzed the data from 276 THA's performed (129 in men, and 147 in women). Women were noted to be associated with smaller stem sizes compared to men (37.67% in women, 6.11% in men), with 7.48% of women requiring conversion to a different type of implant. There was a significant difference in mean stem size (9.21 in men, 6.70 in women, p < 0.0001). Women also required reduced neck options significantly more often than men (38.97% in women, 9.29% in men, p < 0.0001). CONCLUSION: Review of femoral stem sizes reveals that current femoral stem sizing may not appropriately account for women and alternative stem options should be available if using a metaphyseal fitting single tapered stems. Future consideration should be given to more anatomic female sized femoral stems or alternative options should be available.

Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative.

BACKGROUND: In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation. METHODS: Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons. RESULTS: There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%. CONCLUSIONS: Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.

Cannulated screw with solid core insert: stronger than cannulated screws.

We conducted a study to determine if there is a significant difference in ultimate load, yield strength, and fatigue strength between solid core screws and cannulated screws and if a solid core insert placed inside a cannulated screw would have biomechanical effects similar to those of a solid core screw. Five screw designs were tested: Synthes 4.5-mm solid core and 4.5-mm cannulated and our prototype 4.0-mm solid core, 4.0-mm cannulated, and 4.0-mm cannulated with solid core insert. Biomechanical testing with 3-point bending was used to determine ultimate load, yield strength, and cycles to failure for 6 screws of each design. Ultimate load, yield strength, and cycles to failure were significantly (P < .05) lower in the Synthes 4.5-mm cannulated screws than in the Synthes solid core screws and significantly lower in the prototype cannulated screws than in the prototype solid core screws (P < .05) and prototype cannulated screws with solid core inserts (P < .05). There was no significant difference (P > .05) in ultimate load, yield strength, or cycles to failure between the prototype cannulated screws with solid core inserts and the prototype solid core screws.

Total patellar skin loss from cryotherapy after total knee arthroplasty.

The use of cryotherapy after total knee arthroplasty is a very common therapeutic adjunct accepted as routine postoperative care. We present 2 cases of total patellar skin loss due to cryotherapy after total knee arthroplasty. Substantial soft tissue defects were created after the initial debridement of the necrotic tissue. Both patients were evaluated for frostbite, and the wounds were sharply debrided. Application of an advanced wound management technique involves the use of a collagen-glycosaminoglycan biodegradable bilayer matrix, silver impregnated antimicrobial dressing, and low-pressure vacuum device, followed by delayed split thickness skin grafting and low-pressure vacuum device. We find that this technique provided durable soft tissue coverage for necrotic wounds of the knee that do not involve the joint capsule.

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) does not provide long-term symptom control.

The Stretta procedure (radiofrequency energy application to the lower esophageal sphincter) is a unique endoluminal technique for the management of gastroesophageal reflux. This article reports on the long-term effectiveness of the Stretta procedure in patients with significant gastroesophageal reflux disease (GERD) referred to a surgical practice. Patients who underwent Stretta with a minimum of 36 months follow-up were included. Thirty-two patients with an average follow-up of 53 months were included; 19 proceeded to anti-reflux surgery. Those not undergoing surgery showed a significant improvement in their GERD satisfaction from 3.14 to 1.46 (P = .0006) but had significantly lower preprocedure heartburn scores (2.43) than those who proceeded to surgery (3.66, P = .0401). The Stretta procedure was effective in reducing symptoms in 40% of patients. Responders had less severe preoperative heartburn. Radiofrequency energy delivery to the lower esophageal sphincter may be effective in selected patients for the treatment of gastroesophageal reflux.

Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy.

BACKGROUND: Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques. METHODS: All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test. RESULTS: Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation. CONCLUSIONS: Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.

Delivery of radiofrequency energy to the lower esophageal sphincter improves symptoms of gastroesophageal reflux.

BACKGROUND: The Stretta procedure has been proposed as a novel therapeutic alternative to antireflux surgery for gastroesophageal reflux disease (GERD). Early reports indicated improvement in GERD symptoms overall, but improvement in patients who have poor outcome after surgery remains unclear. METHODS: Patients with reflux who did not have a hiatal hernia were offered the procedure. All were administered a GERD Health Related Quality of Life survey at preprocedure and at greater than 3 months postprocedure. Differences in pre- and postprocedure responses were deemed significant with the use of the Wilcoxon rank sum test with P <.05. RESULTS: Fifty patients underwent the Stretta procedure. There were no complications. All were evaluated postprocedure, with 74% completing a postprocedure survey. Overall heartburn score improved from 3.19 (scale, 0-5) preprocedure to 1.74 postprocedure (P=.0012). Overall symptoms satisfaction score improved from 3.92 to 1.63 (P=.0001). Symptoms satisfaction score of patients who failed antireflux surgery improved from 3.5 to 1.75 (P=.0166), and, in those with a body mass index >30, it improved from 4.11 to 1.56 (P=.0024). Four patients went on to have antireflux surgery after having the Stretta procedure. CONCLUSIONS: Stretta improves heartburn symptoms both overall and in patients with poor outcome after antireflux surgery, with a low procedural risk. It may have a role in the treatment of patients with primary reflux and in those who have failed antireflux surgery or who are a high risk for surgery.