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Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_II | Pages 124 - 124
1 Feb 2003
McGregor-Riley J Ali F Hussainy HA Sukumar S
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This study examines the value of a proforma in improving the standards of orthopaedic operation notes. The standard of operation notes in orthopaedic surgery is notoriously poor. This has clinical, medicolegal and research implications. There is no published study on the influence of a proforma on the quality of orthopaedic operation notes. An audit of the quality of operation notes in the orthopaedic department of Chesterfield and North Derbyshire Royal Hospital was undertaken. 1, 928 cases were identified from theatre log books and 88 randomly selected casenotes were scrutinised by a single observer for the legible inclusion of parameters based on Royal College of Surgeons guidelines. An operation note proforma was devised and used routinely over a period of six weeks. The effectiveness of the proforma was assessed by examining operation notes randomly selected from the procedures performed during that period. Identical parameters were assessed. Results from the two groups were compared and statistically analysed using the Wilcoxon signed ranks test. To investigate the longer term impact of proformas an identical audit was undertaken in a neighbouring unit in which a proforma had been in use for five years. Following introduction of the proforma in Chesterfield there was a statistically significant increase in the inclusion of the assessed parameters (p=0. 001). Criteria such as the patient ID number, pre-op diagnosis, tourniquet use and time, prophylactic antibiotic administration, prosthesis details and post-op instructions showed a marked improvement. No parameter showed a significant reduction in its documentation rate. The results from Rotherham were comparable to those achieved following the introduction of the proforma in Chesterfield. This study clearly demonstrates the effectiveness of a proforma in improving the standard of operation notes. The results from Rotherham suggest that high standards can be maintained long after the introduction of the proforma. We recommend the routine use of operation note proformas in orthopaedic surgery


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 264 - 264
1 Jul 2008
IRRAZI M SELLIES J BERRICHI A BEAU P IONESCU N CUNY C
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Purpose of the study: Surveillance of operative site infections (OSI) is a persistent problem in orthopedic surgery. In France, a specific administrative directive was issued on December 29, 2000 to regulate surveillance of OSI. Material and methods: Based on evidence reported in the literature, the efficacy of any surveillance plan requires a sufficiently dense data base obtained by long-term and systematic registration of all significant information concerning all orthopedic surgery patients. Of particular importance are the ASA score, Altmeier, and antibiotic prophylaxy. During the five-year period from 1999 through 2004, a total of 8811 consecutive orthopedic surgery procedures were followed prospectively. Infections detected were registered using a dedicated software. The hospital hygiene committee and the referring surgeon performed the follow-up. Results: On average, infection developed four months after surgery. The rate of infection was 1.2% in 1999 and declined to 0.6% in 2003 with the implementation of a few prophylactic measures. It was possible to determine which operations and which patients were at risk using as criteria the type of operation and the ASA score. Discussion: Surveillance of OSI, with adjustment for risk factors, enabled a measurement of the risk of infection and enabled us to recognized a trend within our department. This study enabled us to define the level of risk for our patients and also develop a new preventive policy. Our findings led us to modify certain practices. Certain data reported in the literature concerning antibiotic prophylaxy were confirmed. Conclusion: This work demonstrated the importance of following operative site infections, disclosed the implications for medical and hospital personnel, and demonstrated the efficacy of preventive measures for decreasing the rate of these infections


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 45 - 45
1 Mar 2013
Conditt M Branch SH Ballash M Granchi C
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INTRODUCTION. Adult reconstructive orthopedic surgery in the United States is facing an imminent logjam due to the increasing divergence of the demand for services and the ability for the community to supply those services. In combination with several other factors, a perfect storm is brewing that may leave the system overtaxed and the patient population suffering from either a lack of treatment, or treatment by less qualified providers. A key component to improving the overall efficiency of surgical care is to introduce enabling technologies that can effectively increase the throughput while simultaneously improving the quality of care. One such enabling technology that has proven itself in many industries is robotics, which has recently been introduced in surgery with even more recent applications in orthopedic surgery. A surgeon interactive robotic arm has been developed for partial knee arthroplasty (PKA) and total hip arthroplasty (THA). This study aims to analyse the efficiency of a new robotic technology for use in orthopaedic surgery. METHODS. 18 robotic arm assisted PKA's across 10 sites were recorded to accurately capture the timeline elemental tasks throughout the procedure. Two camera angles were set up to capture both surgical staff group dynamics and individual procedural steps. 17 tasks were identified and measured from video data. (Fig 1) The robotic arm specific tasks were analyzed for correlation to total surgical time (measured as first incision to last suture). The tasks for the surgeons with the shortest and longest total times were compared directly to determine areas of opportunity. RESULTS. Average total time across 18 surgeries was 55 ± 19 min (range: 30–98 min). There was no correlation between bone registration time and total time (p=0.271) and no correlation between femoral burring time and total time (p=0.230). Per task time comparison of the two surgeons exhibited an average time variation of 3.5 min per task (range: 0.7–8.4 min) (Fig 2). The robotic elements of the procedure exhibited an average time variation of 3.3 min per task while the non robotic elements of the procedure (boxed) exhibited an average time variation of 3.8 min per task. CONCLUSION. Our preliminary results indicate that introducing robotic technology in to the OR does not directly lead to an increase in total surgical time. On average, non robotic specific elements of the procedure exhibited a larger opportunity for efficiency gain. This is likely due to the fact that a large population of surgeon users are not only new to the robotic technology, but new to PKA. Further video collection and analysis will lead to an efficiency benchmarking program that aims to establish methods for best practices in achieving efficiency throughout a robotic arm assisted PKA procedure


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 54 - 54
1 Mar 2008
Furey A Stone C Martin R
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Wrong site surgery is a preventable problem. In 1994 the Canadian Orthopaedic Association (COA) began an educational program initiated to prevent such mistakes from occurring. The purpose of this study was to assess the proportion of orthopedic surgeons who mark their sites preoperatively. This study confirms a high proportion (74.9%) of surgeons in Canada follow the COA guidelines at least occasionally with over half (52.1%) consistently “signing their sites.”. Wrong site surgery is often a catastrophic, but preventable problem. Reports of wrong site surgery have been on the rise in the United States every year since 1995. In 1994 the Canadian Orthopaedic Association (COA) began an educational program initiated to prevent such mistakes from occurring. Their recommendations involved marking the incision site preoperatively. Since that time the claims of wrong site orthopedic surgery have diminished. The purpose of this study was to assess the proportion of orthopedic surgeons who mark their sites preoperatively. Two hundred orthopedic surgeons across Canada were asked to complete a survey concerning preoperative incision site marking. A response rate of 89.3% was achieved. Eighty seven (52.1%) stated they always marked their incision site, thirty eight (22.8%) stated they occasionally marked their incision site, while forty two (25.1%) claimed to never mark their incision site preoperatively. Surgeons in academic centers were more likely to sign their sites than their community counterparts (p=0.021) and surgeons in practice longer were less likely to comply with the COA recommendation (p=0.023). The COA and American Academy of Orthopedic Surgeons (AAOS) have recommended marking incision sites preoperatively in an attempt to reduce wrong site surgery. This study confirms a high proportion (74.9%) of surgeons in Canada follow the COA guidelines at least occasionally with over half (52.1%) consistently “signing their sites.”


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 337 - 338
1 May 2006
Ilsar I Weil Y Mosheiff R Joskowicz L Peyser A Liebergall M
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Introduction: To enable navigated-assisted orthopedic surgery, a reference frame must be rigidly fixed to a stable bony structure. This may create technical obstacles and wound complications. Instead, we propose to attach the reference frame to the fracture table. Methods: The study population consisted of 10 patients who underwent fixation of subcapital femoral neck fracture with three cannulated screws, using fluoroscopy-based navigation. Step 1 – the patient was positioned on a fracture table and the reference frame was attached to the iliac crest. Three guide wires were inserted under fluoroscopy-based navigation. 2 – New fluoroscopic images were acquired. 3 – Navigated drill guide placed over each guide wire to record final navigated drill guide position – these images include actual guide wire positions and the trajectories of the navigated drill guide. Navigation accuracy was validated, measuring translational and angular deviations of the virtual trajectory from the implant on the same fluoroscopic image in anteroposterior and lateral views. 4 – The reference frame was removed from the iliac crest and attached to the fracture table. Step 3 was then repeated. Results: The translational deviation of the virtual trajectory from the inserted guide wire when the reference frame was attached to the iliac crest was not statistically significant from the deviation when it was attached to the fracture table. Angular differences were also not statistically significant. Conclusions: In our experience, attaching the reference frame to the fracture table instead of to the iliac crest allows for similar accuracy of the navigation process with the possible benefit of reducing patient morbidity


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 561 - 561
1 Nov 2011
Gandhi R Rampersaud YR Mahomed NN Hudak P Veillette C Syed K Lewis S Davey JR
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Purpose: Factors influencing patient willingness to undergo elective surgery are poorly understood. Method: We prospectively evaluated patient concerns prior to surgical consultation for elective spinal, hip, knee, shoulder/elbow (S/E), or foot/ankle (F/A) conditions. Patients were surveyed for demographic data, SF 36 quality of life (QOL) scores and asked to report their greatest concern about considering surgery for their condition, as well as their willingness to undergo surgery if it was offered to them by their treating surgeon. Results: In our prospective cohort of 743 patients, 364 (51%) were male and 293 (39 %) were evaluated for a spine condition, 74 (10 %) hip, 192 (26 %) knee, 69 (9 %) S/E, and 115 (16 %) F/A. Mean QOL scores were similar for patients across specialities. The top three greatest concerns for undergoing elective musculoskeletal surgery were potential complications (20%), effectiveness (15%) and recovery time (15%) of surgery. When categorized by specialty, concern of surgical complications was the most prevalent in spine (23%) and F/A patients (30%). However, patients were most commonly unsure of risks associated with their respective subspecialty surgery (spine – 56%; hip – 53%; knee – 44%; S/E – 48% and F/A – 33%). The majority of hip patients (89%) perceived a high success rate for hip surgery, while 65% of spine patients where unsure of the success of spine surgery. Patient willingness to undergo surgery was greatest for hip (84%), knee (78%), and S/E (82%) surgery and least for spine (68%) and F/A surgery (74%). Conclusion: Although patient willingness to consider surgery is clearly a multifactorial decision, patient perception of surgical risk or success prior to surgical consultation are significant factors


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 84 - 84
1 Mar 2010
Minguez JP Otero RC Sixto AG Follente JC
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Introduction and Objectives: In this study we attempted to analyze the biocompatibility of 3 different materials used in Orthopedic Surgery, Titanium, Tantalum and Hydroxyapatite, measuring their adsorption of fibrinogen by means of real time in vitro studies quantifying the mass of fibrinogen that becomes deposited on them. Materials and Methods: We assessed fibrinogen adsorption on these biomaterials by means of quantitative studies using the QCM-D system and qualitative studies reviewing fibrinogen adhesion, by atomic microscopy. For the statistical analysis of the results of this study we used SSP 14.0. Results: The results of the measurement of fibrinogen adsorption on the biomaterials used proved that when low concentrations of fibrinogen were used, 33 ng/ml, Ti and Ha adsorbed fibrinogen relatively rapidly, but Ta does not. However, when we used high concentrations of fibrinogen, 100 ng/ml, Ta adsorption increased markedly. When concentrations greater than 1000 ng/ml of fibrinogen were used, Ta was the biomaterial that showed most fibrinogen adsorption. Discussion and Conclusions: The adsorption of proteins from body fluids is the first biological response to the implantation of a biomaterial, and this protein adhesion will guide cell adhesion on the implanted biomaterial. In our in vitro study, carrying out measurements in real time, we saw that Ta was the material with greatest biocompatibility


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_II | Pages 156 - 156
1 Feb 2004
Konstantopoulos G Konstantopoulos K Papaioannou E Dounis E Proveleggios S Kostakis S Tsinari K
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Aim: Our aim was to record our experience with a fine needle 27G with any possible difficulties and side-effects. Methods: 38 patients (26 men, 12 women) were selected for our study, aged 18–33 years. The underwent orthopedic surgery (femoral fractures, ankle surgery, patella, tibia and fibula fractures). The patients were preloaded with 500–700 ml crystalloid fluids.Lignocaine 2% (2–4ml) was injected for skin infiltration. The spinal was performed in lateral positioning in O3–O4 or O4–O5 spaces. Bupivacaine (Marcaine 0.5%) was injected and clonidine (Catapresan) was added in 8 cases for prolonged anaesthesia. The injection was slow and the patients were evaluated in 1, 12, 24, 48 hours. Results: Headache – technical difficulties – delayed action – nausea and vomiting and urine retention were recorded. Headache. Even though all the patients were well informed for 24th bed rest, 2 of them suffered headache. They were treated with fluids, paracetamol, bed rest. No headache was noted after 72 hours. Technical difficulties. Multiple tries were needed for successful spinal in 3 obese patients. Delayed action. In 4 cases the onset of spinal anaesthesia took more than 20min. One patient was finally given general anaesthesia because of the spinal failure. No urine retention was recorded. Nausea – vomiting. 3 patients suffered nausea and were given ondasertron. No vomiting was recorded. Conclusion: We conclude that spinal anaesthesia in young patients doesn’t cause severe side-effects nor technical difficulties. Headache, nausea, vomiting are less common in spinal than general anaesthesia


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 233 - 233
1 Mar 2004
Eriksson B Bauer K Lassen M Turpie A
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Aims: In major orthopedic surgery, fondaparinux provided a major benefit over enoxaparin, with an overall venous thromboembolsim (VTE) risk reduction of > 50% and similar safety profile regarding clinically relevant bleeding (leading to death or reoperation, or occurring in critical organ). The aim of the present study was to analyze this superior efficacy according to patients and surgery characteristics. Methods: In four phase III trials, the primary efficacy outcome was the VTE incidence up to day 11, defined as deep-vein thrombosis (DVT) detected by mandatory bilateral venography or documented symptomatic DVT or pulmonary embolism. Primary efficacy was further analyzed according to predefined categorical covariates using a logistic regression model. Results: Fondaparinux was more effective than enoxaparin irrespective of age, gender, obesity, the use of cement or surgery duration (odds reduction from −46.9% to −59.7% in favor of fondaparinux. Clinically relevant bleeding did not differ between the two groups according to predefine covariates. Conclusions: For VTE prevention in major orthopaedic surgery, the superiority of fondaparinux over enoxaparin was consistent irrespective of patient or surgery characteristics


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 6 - 6
1 Mar 2006
Borris LC
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According to the 2004 ACCP guidelines on antithrombotic and thrombolytic therapy general extended prophylaxis with low molecular weight heparins, vitamin K antagonists, or fondaparinux is recommended after major orthopedic surgery. This recommendation is based on a number of placebo controlled, clinical studies using venographic screening for deep vein thrombosis (DVT), as a surrogate end-point for pulmonary embolism (PE), other vascular thrombotic events were not considered. In a recent meta-analysis on these studies the overall event rate of symptomatic venous thromboembolism 30–42 days after a joint arthroplasty was 2.7% DVT and 0.6 % PE in patients having short-term prophylaxis and it was significantly reduced by extended prophylaxis. Bleeding episodes were seen in 4% of cases having extension. Taking into consideration the risk benefit for the individual patient do these findings justify that extended prophylaxis is used on a general basis? To answer this question also compliance, adverse event profile, and cost of the prophylactic regimens have to be addressed. It would be very attractive to be able to individualize the duration of the prophylactic period by assessing the thrombotic potential of every patient in order to balance the risks and benefits of continued prophylaxis


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 232 - 232
1 Mar 2004
Eriksson B Bauer K Lassen M Turpie A
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Aims: The fondaparinux thromboprophylaxis phase III studies database including 7344 patients in orthopaedic surgery provides information regarding patient management according to country specificities. Methods: 4 randomized double-blind trials were conducted in 376 centers in 23 countries comparing fondaparinux to enoxaparin – 1 in major knee surgery (MKS) in North America (NA); 2 in total hip replacement (THR) in NA and in Europe, respectively; and 1 in hip-fracture (HF) surgery worldwide except in NA. The use of regional anesthesia or cement during surgery, use of stockings during hospitalization, or prolonged prophylaxis (PP) after discharge were left to the investigators. Results: In all studies the majority of patients were women, particularly in HF. The median age was 67 years for THR, 69 years for MKS, and 79 years for HF. In THR studies, regional anesthesia was used more frequently in Europe (59%) than in NA (24.4%). The table summarizes investigators’ practice. Conclusions: There are important differences in the management of orthopedic surgery patients according to country specificities and type of surgery. However, fondaparinux is more effective than enoxaparin for thromboprophylaxis irrespective of patient or surgery characteristics


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_I | Pages 86 - 86
1 Jan 2003
Kuenzler S Gross I Knappe P Pieck S Wahrburg J Kerschbaumer F
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In the framework of the modiCAS (Modular Interactive Computer Assisted Surgery) Project, which emerged from a collaboration of the University of Siegen and the University of Frankfurt in the fields of mechatronics and medicine, the development of a modular system to assist the surgeon during the whole planning and operation procedure has been started. A completely new realization of a planning system for bone surgery and alloarthroplasty is presented. Characteristics of the new system are generic interfaces for navigation, robotics and real-time data acquisition, graphic interactivity, documentation of each planning-step, a flexible wizard-guided concept and adaptable teaching modes. The system can be configured to any data source such as X-ray, CT, MRI, US with individual calibration. For planning, the data sources can be merged in any user defined way. In contrast to all existing planning systems the presented system can optionally be linked to navigation and robotic systems.

The software was realized to run platform-independent on any personal computer surrounding. We used commercially available software libraries for computer graphics and graphical user interface programming. The whole system consists of several modules which are closely linked together and support all major pre- and intraoperative steps of surgery. The user interface remains the same during the planning and the intervention. Preoperative planning is carried out on a totally new planning station comprising an interactive and intuitive graphic interface, while intraoperative features include interactive matching procedures, true real-time-capability and incorporation of navigation and robotics.

Initially we realized modules to support total hip allo-arthroplasty. The first application of the system is for a clinical trial on total hip alloarthroplasty. Planning is performed on the basis of radiographs and CT-datasets. Intraoperatively a navigation system and a robotic surgery system are used. Preliminary results show very precise and reproducible plannings that could be achieved in short time without special training of the clinician. Furthermore the unlimited intraoperative access to the whole planning dataset appeared to be very convenient to the surgeon because it allowed immediate response to unforeseen patient specific situations.

Future adaptations of the universal planning system will be total knee alloarthroplasty, spine surgery and trauma surgery. The existing system can easily be configured to any surgical procedure because the same basic functionality is used for all applications and only special configurative datasets have to be generated for each application.

The open architecture of the system enables easy integration of further input or output devices, an easy adaptation to different interventions, planning styles and operative techniques is possible.


Background: Postoperative thromboses are among the most feared complications in orthopedic surgery, possibly causing life-threatening conditions in otherwise highly successful procedures such as total joint replacement. Body weight is an important risk factor for thromboses and is being used in algorithms to determine dosages in prophylaxis. However, weight patterns among orthopedic populations have changed considerably since the introduction of these algorithms, essentially shifting towards obesity. This study asks whether present-day obese patients are essential under-dosed and would benefit from higher than usual dosages of bemiparin sodium in the prophylaxis of postoperative thrombosis. Patients and Methods: To ensure sufficient power a sample of 750 patients, allocated into two cohorts receiving either 3,500 IU or 5,00o IU bemiparin sodium were followed postoperatively for 6 weeks and blindly assessed for clinically symptomatic thrombotic events. Differences in rates of thrombotic events were modeled using mulitvariate Poisson regression including potential confounders severity of immobilisation, gender, exact weight, and age as covariates. A p-value of 5% was considered significant. Results: Information on 723 patients for a total of 66.8 person-years was analysed per intention-to-treat. The adjusted incidence rate ratio was 0.35 (95%CI: 0.03 to 2.91). Thus there was not evidence for a difference in rates between groups. There was, however, a borderline significant association between rates and body weight, suggesting a potential benefit of higher dosages in even heavier patients. There were no complications due to higher dosages of bemiparin sodium. Conclusion: We did not see a significant reduction of incidence rates of thromboses with higher dosages of bemiparin in this population. However, there was some evidence that higher dosages might prove beneficial as populations further gain weight


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 516 - 516
1 Aug 2008
Somger-Jordan J Papura S Loberant N Shtarker H Volpin G
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Introduction: Arterial bleeding following pelvic fractures is widely recognized as an indication for angiography and embolization although controversy persists as to the timing of this procedure in the treatment algorithm. Less well appreciated is its application in similar circumstances following blunt injury to the pelvic arteries and limb injuries. We describe our experience in a variety of haemorrhagic orthopaedic pathologies.

Patients and Methods: Angiography was performed in 29 patients- 16 with pelvic fractures, 9 with extremity injuries, and 4 with tumors. Seldinger technique was used for angiographic access, usually from the groin although on occasion extensive local injury required use of the brachial approach. Following the initial diagnostic study the a selective catheter was placed at the target, appropriate embolic material was selected and the source of haemorrhage was closed off.

Results: In our experience of pelvic traumatic bleeding (14 associated with fracture, 2 without) embolization was successful in promptly arresting hemorrhage in all but one case of advanced DIC. Mortality was confined to this last case and two others, all of whom were referred for embolization following prolonged hypotension and commenced angiographic intervention with blood pressure unmeasureable or of the order of 30mm systolic. With 9 cases of extremity injury, 1 iatrogenic, 5 penetrating, 2 blunt and one following fracture of the femur, embolization successfully treated the hemorrhage. Finally we present our experience in preventing hemorrhage in 4 cases, 3 of which were vertebral body tumours and 1 pathological fracture of the humerus due to RCC. At surgery following embolization none bled significantly.

Conclusions: The present study describes our experience in various orthopedic conditions. Less well recognized is its role in preventing hemorrhage; as a prelude to bloody operations on vertebral body metastases, aneurysmal bone cysts and hemangiomata as well as open reduction and internal fixation of pathological extremity fractures. We conclude that this technique is a valuable addition to the tools available to the orthopedic surgeon and whose application is not necessarily limited to the examples quoted, but should be applied in any case where the direct surgical approach is considered hazardous or ineffective.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_I | Pages 20 - 20
1 Mar 2002
Siebert C Wirtz D Gottschalk D Niedhart C
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Among the wide variety of bone substitutes presently available, pure β-tricalcium phosphate ceramics have become available (Biosorb®; Aesculap, Tuttlingen). During the first 12 months of a prospective clinical trial, Biosorb® products were implanted in 21 patients. The ceramics were used in a variety of clinical settings, ranging from pelvic osteotomies in children (n=9), to filling of bone cysts or osseous defects (n=4), to dorsal spondylodesis (n=6), as well as for the grafting of pseudarthroses (n=2). Average follow-up period was 13 (6–18) months.

The β-TCP granules, when used as part of a composite graft in combination with autologous bone, were completely resorbed after an average period of 14 weeks, while the cubes required 12 to 15 months. The more massive wedges have shown only a decrease in size and radio density. Due to the ability of the cubes and wedges to bear loads of up to 30 MPa, they were successfully implanted during pelvic osteotomies to augment or completely replace the bicortical grafts. Complications or foreign body reactions were not noted. The osseointegration was found to be favorable for all forms.

In light of the problems associated with autologous and allogeneic grafts, the use of synthetic bone substitutes will continue to increase. The combination of complete resorption, lack of risk of infection, and load sharing ability make the β-tricalcium phosphate implants a valuable addition to the spectrum of bone replacement products presently available. Their use in pediatric orthopedics could help avoid donor site morbidity including contour changes or growth disturbances, while providing a more stable graft. During the first phase of a prospective clinical trial, we have come to the conclusion, that the β-tricalcium phosphate ceramics represent a real alternative to other bone substitutes.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 621 - 621
1 Oct 2010
Vavken P Dorotka R
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Introduction: Meta-analyses are an important instrument in orthopaedic surgery, not only to create clinical guidelines, but also because their findings are included in public health and health policy decision-making. Generally, meta-analyses of randomised controlled trials are considered as the highest level of evidence. However, with increasing numbers of meta-analyses, discordance and frank conflicts in results have been seen, which might lead to grave complications considering the aforementioned facts. The purpose of this study was to search for conflicting meta-analyses in orthopaedic surgery, i.e. such arriving at different conclusions despite following the same research question; to identify potential reasons for, and to assess the actual amount and significance of such differences.

Methods: We searched the online databases PubMed, EMBASE and the Cochrane Controlled Trial Register for orthopaedic meta-analyses and cross-referenced results within and across databases to identify meta-analyses focusing on the same subject. Meta-analyses were defined as conflicting if they arrived at different results despite studying the same populations.

To assess the significance of such difference we used Cochrane’s Q-test. To test the amount, thus clinical meaning, of differences we calculated the I2-index, the amount of difference beyond random chance. Since both these parameters depend on study size, we also calculated the “uncertainty interval” (UI), which, in accordance to the 95% confidence interval contains the true I2-index of the whole population.

Results: We were able to identify conflicting meta-analyses on graft choice in ACL reconstruction (n=7), the use of hyaluronic acid (n=5) and pulsed electromagnetic fields in osteoarthritis (n=2). Significant differences could only be shown among meta-analyses on hyaluronic acid (p< 0.001). The uncertainty intervals were 38.6% to 78.6% for hyaluronic acid, 0% to 41.1% for ACL and 0% to 99% for electromagnetic fields in osteoarthritis.

Discussion: There are conflicting meta-analyses in orthopaedic research, posing a threat to evidence-based treatments. It seems, however, that a considerable amount of conflict derives from differences in the interpretation of pooled results rather than from the results themselves. In summary, findings and interpretations of meta-analyses should be as critically scrutinized as in any other type of study and subjected to re-assessment if deemed necessary.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 111 - 111
1 Mar 2009
Fevang B Lie S Havelin L Engesæter L Furnes O
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Objective: To study the incidence of joint replacement procedure, arthrodesis, and synovectomy among patients with chronic inflammatory joint disease during the period 1994 to 2004.

Methods: Data from the Norwegian Arthroplasty Register was used to find the number of joint replacement procedures performed in Norway 1994 – 2004. The incidences of arthrodeses and synovectomies were obtained from the Norwegian Patient Register. Incidence rates were calculated based on age, year, and gender specific population rates for the Norwegian population, obtained from Statistics Norway.

Results: There were 8268 primary joint replacements, 3554 arthrodeses, and 5012 synovectomies performed in patients with inflammatory arthritis (IA) during the study period. A reduction in joint replacement procedures and synovectomies took place during the period 1994 to 2004, in patients with IA. For the oldest patients (80 years and older), no such trend was found. During the same time period, the incidence of joint replacements due to osteoarthritis increased. A significant reduction in the incidence of arthrodesis procedures was also found for the total study group, but not for the different subgroups.

Conclusion: The incidence of joint replacements and synovectomies among patients with chronic inflammatory joint disease decreased from 1994 to 2004. This may be the result of improved medical treatment of these patients.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 607 - 608
1 Oct 2010
Matamalas A Palou EC García A Horcajada J Martínez-Díaz S Pelfort X Puig L Salvadò M Sorli L
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Background: The presence of bacteria forming biofilms or prior antimicrobial use has been shown to reduce the sensitivity of the standard technique (PT cultures) in patients with infection of orthopedic implants. Culturing fluid resulting from sonication (FRS) of prosthesis could improve the microbiologic diagnosis.

Objective: To analyze the diagnostic validity of culturing FRS of different orthopedic implants and PT culture

Methods: Between Jan 2007 and Apr 2008, patients undergoing knee or hip prosthesis removal, and those with ostheosyntesis or spinal instrumentation removal, were prospectively included (44 hip prosthesis, 63 knee prosthesis, 91 osteosynthesis and 14 spinal instrumentations). 5 PT specimens were collected for culture. Removed implants were sonicated during 5 min. (40Hz). Both, PT and FRS, were inoculated in aerobic agar (Chocolate Polyvitex), anaerobic agar (Schaedler + 5% blood) and in thioglycolat, for 7 days. Positive culture cut-off was defined as growing of > 5 CFU. Clinical diagnosis of prosthetic-joint infection was made as commonly accepted. Previous antimicrobial therapy was assessed. Diagnostic validity was calculated for both culturing methods. Sensitivity of methods was compared by Chi-square test (SPSS 15.0).

Results: 212 cases were included. Diagnostic of infection was made in 17 hip prosthesis (THA), 20 knee prosthesis (TKA), 24 osteosynthesis (OS) and 6 spinal fusions (SI).

Tissue culture was positive in 9 THA, 11 TKA 18 OS and 4 SI. Sonication culture was positive in 14 THA, 18TKA, 23 Os and 6 SI.

Tissue culture: Sensibility: THA53%, TKA 55%, OS 75% and SI 66%. Specificity: THA 96%, TKA 100%, OS 96%, SI 100%

Sonications: Sensibility: THA 82%, TKA 90%, OS 95% and SI 100%. Specificity: THA 96%, TKA 100%, OS 92%, SI 100%

Statistical differences favoring sonication were found in sensitivity in knee arthroplasty and osteosynthesis implants. 6 patients received antibiotics for > 7 days before implant was removed. Sonication culture was positive in 4 of them whereas only one standard culture yielded positive.

Conclusions: FRS cultures are more sensitive than PT cultures. Sensitivity of the method depends on which device is evaluated. Sonication also improves sensitivity of culture after preoperative antimicrobial therapy.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 377 - 377
1 Jul 2008
Bhattacharyya M Gerber B
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Malpositioning of the component of a total knee implant and malalignment of the leg is one of the significant factors for the outcome after Total Knee Arthroplasty.

Previous studies have shown that the use of a navigation system can improve these. This article presents the initial results of a prospective and non-randomised study describing navigated implantation in TKA with special reference to soft tissue balancing in knees with posttraumatic deformity. The secondary objective is to found out reproducibility of the software.

Methods: Since January 2004, 15 patients with post-traumatic arthrosis of the knee and axial malalignment of more than 15 degrees, pre operative arc of motion 75 degrees admitted to our senior author for TKA have been followed up prospectively. The data were collected over a period of 25 months. Apart from the usual clinical evaluations, no patients had CT of the leg prior to the operation & postoperatively. Intra-operative and peri-operative morbidity data were collected and blood loss measured.

Results: A postoperative leg axis between 3 degrees varus and 3 degrees valgus was obtained in all of the navigated knees after soft tissue balancing. The alignment of the components using computer-assisted surgery in regard to femoral varus/valgus, femoral rotation, tibial varus/valgus, tibial posterior slope, tibial rotation are reproducible and consistent. Computer-assisted surgery took longer with a mean increase of 31 minutes for kinematic data acquition. Intraoperatively we achieved range of motion more than 120 degrees. No patient required manipulation postoperatively for improving range of motion

Conclusion: These results support that the precise surgical reconstruction of the mechanical axis of the knee and proper alignment of the component is achievable in patients who suffered posttraumatic deformities and secondary arthrosis by using an intraoperative navigation system.

It has been mentioned in the literature that minor deviations in the insertion point of Intramedullary instrumentation during TKA may result in malalign-ment of several degrees [Nuno-Siebrecht 2000], which can be avoided with these soft ware.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_8 | Pages 96 - 96
11 Apr 2023
Crippa Orlandi N De Sensi A Cacioppo M Saviori M Giacchè T Cazzola A Mondanelli N Giannotti S
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The computational modelling and 3D technology are finding more and more applications in the medical field. Orthopedic surgery is one of the specialties that can benefit the most from this solution. Three case reports drawn from the experience of the authors’ Orthopedic Clinic are illustraded to highlight the benefits of applying this technology. Drawing on the extensive experience gained within the authors’ Operating Unit, three cases regarding different body segments have been selected to prove the importance of 3D technology in preoperative planning and during the surgery. A sternal transplant by allograft from a cryopreserved cadaver, the realization of a custom made implant of the glenoid component in a two-stage revision of a reverse shoulder arthroplasty, and a case of revision on a hip prosthesis with acetabular bone loss (Paprosky 3B) treated with custom system. In all cases the surgery was planned using 3D processing software and models of the affected bone segments, printed by 3D printer, and based on CT scans of the patients. The surgical implant was managed with dedicated instruments. The use of 3D technology can improve the results of orthopedic surgery in many ways: by optimizing the outcomes of the operation as it allows a preliminary study of the bone loss and an evalutation of feasibility of the surgery, it improves the precision of the positioning of the implant, especially in the context of severe deformity and bone loss, and it reduces the operating time; by improving surgeon training; by increasing patient involvement in decision making and informed consent. 3D technology, by offering targeted and customized solutions, is a valid tool to obtain the tailored care that every patient needs and deserves, also providing the surgeon with an important help in cases of great complexity