Various reports confirm elevations in serum markers associated with skeletal muscle injury after orthopaedic surgery in the absence of overt clinical manifestations of myocardial injury. We therefore measured the influence surgical approach has on these serum markers after primary THA. We nonrandomly enrolled 30 nonconsecutive patients undergoing THA in three groups of 10 based on current surgical approaches used at our facility: (1) minimally invasive (MIS) modified Watson Jones approach; (2) miniposterior transmuscular approach (MIS-I); and (3) MIS-II incision. Blood samples for hemoglobin, hematocrit, cardiac troponin I, total creatine kinase, creatine phosphokinase, and serum myoglobin were obtained the morning before surgery as a baseline, immediately postoperatively, and 72 hours thereafter. We found reproducible trends in serum enzyme levels consistent with skeletal muscle damage resulting from primary THA. Troponin I remained normal in all but one patient indicating no myocardial contribution to measured serum enzyme levels. All three procedures resulted in similar trends in serum enzyme markers relevant to primary THA. Our preliminary data suggest no surgical approach appears to affect the degree of muscle trauma more or less than another.
Cementless fixation design failures led to low use of this alternative technology. A cementless total knee arthroplasty addressed these design flaws. The single radius knee design incorporated additive manufacturing to produce the tibial and patellar implants. Both implants have enhanced porous substrates, optimizing initial bony ingrowth. A nonrandomized prospective review was conducted of 72 cementless knees followed for a minimum of 2 years (mean, 37 months). Surgical time, estimated blood loss, and range of motion at 6 weeks were compared with those of a matched cohort of 70 cemented knees performed by the same surgeon. Knee Society Score and Oxford Knee Score were recorded for the cementless group. Radiographs were evaluated for change in implant position, subsidence, and radiolucent and sclerotic lines. Operative time was statistically shorter in the cementless group (40 vs 45 minutes), but there was no significant difference in postoperative estimated blood loss (557 vs 355 mL). Range of motion at 6 weeks averaged 118° in the cementless group vs 114° in the cemented group. Knee Society Score improved from 53.9 preoperatively to 85.0 at 6 weeks and 91.6 at most recent follow-up. Oxford Knee Score improved from 23.9 preoperatively to 31.7 at 6 weeks and 43.4 at most recent follow-up. No implants aseptically loosened or migrated. There were 2 early infections in the cemented group requiring revision. This cementless total knee arthroplasty revealed excellent clinical results at 3-year follow-up and resulted in shortened operative times. Biologic fixation was achieved in 100% of patients with improved functional and objective scores. Early results are encouraging, and this cementless total knee arthroplasty appears to provide an excellent alternative to cemented total knee arthroplasty. [Orthopedics. 2018; 41(6):e765-e771.].
In a prospective, non-randomized trial, 222 hips across seven centers received the same THA system of a tapered wedge stem and novel additively manufactured titanium porous clusterhole acetabular shell in primary THA. 113 hips were implanted with a robotic-assisted surgical system while 109 hips were implanted manually. The robotic-assisted cohort yielded a similar mean skin-to-skin surgical time of 80.35 minutes compared to 79.35 minutes for the manual cohort (p=0.8895), along with a shorter hospital stay of 0.96 days compared to 1.59 days (p<0.0001). The robotic-assisted cohort resulted in a lower blood loss of 199.8 cc compared to 310.1 cc for the manual cohort (p<0.0001). Standard deviation for incision length was 81% of the value in robotic-assisted cases when comparing with manual cases (2.2 cm vs. 2.7cm). Robotic-assisted THA cases demonstrated improved clinical outcomes with a higher 6-week postoperative HHS (81.0 vs. 78.4), physical VR-12 (39.5 vs. 35.9), and LEAS (9.2 vs. 8.0). The EQ-5D treatment effect size at 6-weeks postoperative for robotic-assisted cases exceeded a large effect with a value of 0.91, while the effect size for manual cases was 0.59. Robotic-assisted 3-D patient specific planning and haptically guided robotic-assisted surgical execution demonstrated an improved operative experience relative to blood loss, and incision length. The robotic cohort also yielded improved early clinical and functional outcomes when comparted to manual techniques at six weeks. These early, enhanced robotic-assisted THA results support surgeons using robotics with the goals of decreased patient pain, greater range of motion, and increased joint stability.
Background: Tuberculous pericarditis (TBP) is a rare clinical entity but carries a high mortality rate (20%-40%). The incidence of TBP among patients with pulmonary TB ranges from 1%-8%. Pericardial involvement is invariably associated with TB elsewhere in the body by infectious extension in the lung, tracheobronchial tree, adjacent lymph nodes, spine, sternum, or by miliary spread. In many adults, TBP represents reactivation disease, making the primary focus of infection less apparent. Symptoms of TBP are related to either fluid overload (i.e. pulmonary and peripheral edema) compromised cardiac output (i.e. fatigue and dyspnea) or both. Physical exam has low yield in the diagnosis, but may demonstrate symptoms of volume overload and compromised cardiac output. ECG and CXR may be suggestive of the diagnosis, but ECHO is currently the gold standard modality for constrictive pericarditis. Treatment of TBP is largely medical. Pericardiectomy is reserved for patients with recurrent effusions or failed medical management. Methods: In the present report, we discuss a healthy 44-year-old Vietnamese woman, who first presented with fever, cough productive of yellow sputum, shortness of breath, and pleuritic chest pain for 9 months. She then underwent extensive work-up and evaluation for persistence and worsening fluid overload and pump failure symptoms. ECHO revealed constrictive pericarditis. Thus, the patient was taken to the operating room for a pericardiectomy. Results: Following surgical intervention, our patient had a rapid and marked clinical improvement. Biopsy of the pericardial tissue revealed caseating granulomas with acid-fast bacilli. Conclusion: Isolated TBP is a rare clinical entity but its diagnosis and prompt management may result in decreased morbidity and mortality. Treatment remains largely medical, but surgical intervention is indicated in those patients with worsening symptoms.
Nearly 500,000 total hip replacements are being done annually. In hopes of reducing the pain and recovery time for these patients, development of less-invasive procedures has been a topic of interest among orthopedists. The purpose of this study is to obtain intraoperative and postoperative data to compare three different total hip arthroplasty procedures: standard (10-12 in. incision), mini-incision (2.5-3.5 in. incision), and the 2-incision approach (1.5 inches each). This study will provide information to determine if minimally invasive surgery (MIS) can reduce rehabilitation time and complication rates when compared to the standard approach. In addition, the learning curve for the challenging two-incision MIS will be determined for three different surgeons over a 17-month period. It is hypothesized that the two-incision MIS approach will reduce rehabilitation time and the number and severity of complications for the 60-day postoperative period. The study is a retrospective chart review of all THAs done by Russell Cohen, MD; Jay Katz, MD; and Scott Slagis, MD from December 31, 2002 through May 31, 2004. The primary endpoints include: length of hospital stay, discharge location, transfusion rates, number and severity of complications for the period of 60-days following surgery, estimated blood loss, length of surgery, operating room staff, number of physical therapy sessions, BMI, incision length, and blood products. Following completion of data entry, statistical analysis will be performed by a biostatistician designated by the sponsor (Zimmer, Inc). Analysis will include mean, standard deviation, max, min, mode, median, and an ANOVA test to the level of p=0.05. This study has the potential to contribute to the understanding of whether MIS is effective in reducing rehabilitation time and complication rates. This information could be beneficial to future hip replacement patients. In addition, knowledge pertaining to the number of surgeries required in order to become proficient in this procedure will aid surgeons who are considering implementation of these methods.
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