The optimal overall lower extremity and component alignment in total knee arthroplasty (TKA) has recently been questioned, yet the majority of studies demonstrate TKA positioning to effect the rate of implant loosening, polyethylene stresses, knee kinematics, and gait. Most commonly, extramedullary tibial and intramedullary femoral alignment guides are used to set coronal alignment in TKA, but these “conventional” methods have a limited degree of accuracy. The goal of obtaining more precise and accurate component positioning has led to the development of computer-assisted surgical (CAS) techniques. Although numerous comparative studies have shown significant improvements with the use of CAS techniques, concerns over increased operative times, large capital costs, and the learning curve associated with their use have limited their widespread acceptance.

Recently, handheld navigation devices have been introduced with the goal of providing the accuracy of large-console CAS systems in an easy-to-use manner. These devices rely on accelerometer-based navigation to set cutting guide alignment relative to the mechanical axes of the femur and tibia. Unlike most CAS systems, handheld navigation systems avoid the use of additional pin sites and reference arrays in the femur and tibia, do not require a large computer with an infrared camera, and thus eliminate intraoperative line of site issues between the camera and tracking arrays. Several investigations have demonstrated handheld navigation devices to provide the same degree of alignment accuracy as large-console CAS systems, thus improving the ability of a surgeon to achieve their intraoperative targets for coronal alignment during TKA.

Computer navigation is an attractive tool for use in total knee arthroplasty (TKA), as it is well known that alignment is important for the proper function of a total knee replacement. Malalignment of the prosthetic joint can lead to abnormal kinematics, unbalanced soft-tissues, and early loosening. Although there are no long term studies proving the clinical benefits of computer navigation in TKA, studies have shown that varus alignment of the tibial component is a risk factor for early loosening.

A handheld, accelerometer based navigation unit for use in total knee replacement has recently become available to assist the surgeon in making the proximal tibial and distal femoral cuts. Studies have shown the accuracy to be comparable to large, console-based navigation units. Additionally, accuracy of cuts is superior to the use of traditional alignment guides, improving the percentage of cuts within 2 degrees of the desired alignment.

Because the registration is based on the mechanical axis of the knee, anatomic variables such as femoral neck-shaft angle, femoral length, and presence of a tibial bow do not affect the results. The handheld aspect of this navigation unit allows its use without additional incisions or array attachment. Furthermore, the learning curve and usage time is minimal, supporting its use in primary TKA.

Computer navigation is an attractive tool for use in total knee arthroplasty (TKA), as it is well known that alignment is important for the proper function of a total knee replacement. Malalignment of the prosthetic joint can lead to abnormal kinematics, unbalanced soft-tissues, and early loosening. Although there are no long term studies proving the clinical benefits of computer navigation in TKA, studies have shown that varus alignment of the tibial component is a risk factor for early loosening.

A handheld, accelerometer based navigation unit for use in total knee replacement has recently become available to assist the surgeon in making the proximal tibial and distal femoral cuts. Studies have shown the accuracy to be comparable to large, console-based navigation units. Additionally, accuracy of cuts is superior to the use of traditional alignment guides, improving the percentage of cuts within 2 degrees of the desired alignment.

Because the registration is based on the mechanical axis of the knee, anatomic variables such as femoral neck-shaft angle, femoral length, and presence of a tibial bow do not affect the results. The handheld aspect of this navigation unit allows its use without additional incisions or array attachment. Furthermore, the learning curve and usage time is minimal, supporting its use in primary TKA.

Computer navigation is an attractive tool for use in total knee arthroplasty (TKA), as it is well known that alignment can affect clinical results. Malalignment of the prosthetic joint can lead to abnormal kinematics, unbalanced soft-tissue, and early loosening. Although there are no long term studies proving the clinical benefits of computer navigation in TKA, studies have shown that varus alignment of the tibial component is a risk factor for early loosening.

A handheld, accerelerometer based navigation unit for use in total knee replacement has recently become available to assist the proximal tibial and distal femoral cuts. Studies have shown the accuracy to be comparable to large, console-based navigation units. Additionally, accuracy of cuts is superior to the use of traditional alignment guides, improving the percentage of cuts within 2 degrees of the desired alignment.

Because the registration is based on the mechanical axis of the knee, anatomic variables such as femoral neck-shaft angle, femoral length, and presence of a tibial bow do not affect the results.

The handheld aspect of this navigation unit allows its use without additional incisions or array attachment. Furthermore, the learning curve and usage time is minimal, supporting its use in primary TKA.

Component and limb alignment are important considerations during Total Knee Arthroplasty (TKA). Three-dimensional positioning of TKA implants has an effect on implant loosening, polyethylene stresses, and gait. Furthermore, alignment, in conjunction with other implant and patient variables such as body mass index (BMI) influence osseous loading and failure rates. Fortunately, implant survivorship after TKA has been reported to be greater than 95% at 20 years, despite up to 28% of TKAs having component position greater than 3 degrees from neutral. How good are we at positioning TKA implants? Ritter, et al examined 6,070 primary TKAs and found that from 2–7 degrees of valgus, the failure rate was 0.5% for limb alignment. Importantly 28% of the TKAs were outside the 2–7 degree range in the hands of experienced surgeons. Clearly there is room for improvement in surgical technique, but this improvement must be (1) time efficient and cost effective; (2) have a low complication rate, and (3) be reproducible with a minimal learning curve. A number of technologies have been developed to help surgeons implant and position TKA components including intramedullary guides, patient matched guides based on pre-operative imaging, Computer Assisted Surgery (CAS) based on line-of-sight navigation, and most recently, hand-held navigation. All of these techniques have distinct advantages and disadvantages, but we have found that hand-held navigation in TKA meets the prerequisites. Nam, et al reported the first series with a handheld device in 42 knees, and was able to position 95% of the tibial components within 2 degrees of targeted sagittal slope and 96% within 3 degrees of coronal alignment. Advantages of hand-held navigation include low cost, minimal learning curve, reproducibility surgeon to surgeon, and time efficiency (usually taking less than 3 minutes). The disposable device can be used on all patients with all deformities, including those with retained hardware. Hand held navigation devices create a virtual alignment framework from known osseous landmarks, and this framework is used to position tibial and femoral cutting guides on the bone. Using tibial osseous landmarks, including the ACL footprint proximally and the medial and lateral malleoli distally, the device allows real-time feedback of tibial slope and coronal alignment. On the femur, the device locates and references the centre of rotation of the hip and the centre of the distal femur, which allows for real-time calculation of distal femoral valgus and flexion for the distal femoral cutting block. Receiving three-dimensional, real-time feedback of coronal and sagittal alignment, as well as resection depth, combining limited mechanical instruments aided by hand-held navigation devices is a significant step forward. Thus, this technology represents a significant help to the surgeon and patient.

Computer navigation is an attractive tool for use in total knee arthroplasty (TKA), as it is well known that alignment is important for the proper function of a total knee replacement. Malalignment of the prosthetic joint can lead to abnormal kinematics, unbalanced soft tissues, and early loosening. Although there are no long term studies proving the clinical benefits of computer navigation in TKA, studies have shown that varus alignment of the tibial component is a risk factor for early loosening.

A handheld, accelerometer-based navigation unit for use in total knee replacement has recently become available to assist the surgeon in making the proximal tibial and distal femoral cuts. Studies have shown the accuracy to be comparable to large, console-based navigation units. Additionally, accuracy of cuts is superior to the use of traditional alignment guides, improving the percentage of cuts within 2 degrees of the desired alignment.

Because the registration is based on the mechanical axis of the knee, anatomic variables such as femoral neck-shaft angle, femoral length, and presence of a tibial bow do not affect the results. The handheld aspect of this navigation unit allows its use without additional incisions or array attachment. Furthermore, the learning curve and usage time is minimal, supporting its use in primary TKA.

Aims

To develop a multidisciplinary health research agenda (HRA) utilizing expertise from various disciplines to identify and prioritize evidence uncertainties in orthopaedics, thereby reducing research waste.

Post-surgical wound infections following total hip or knee arthroplasties can be a potentially catastrophic complication for the patient. Currently, several preventative measures exist to help combat this complication. One such method is skin disinfection with preadmission cutaneous chlorhexidine preparation. Although efficacious in reducing surgical site infections during total joint arthroplasty, orthopaedists should be aware of discrepancies between hip and knee arthroplasty. For example, Kapadia et al. performed a prospective study which evaluated the use of preadmission cutaneous chlorhexidine preparation on the reduction of surgical site infections following total hip arthroplasty; they found that there was a 3-fold higher relative risk of developing infection in patients who did not receive the chlorhexidine preparation as compared to those who did. In a similar study performed for total knee arthroplasty, the same authors founds a 6-fold higher relative risk of developing infection, which equated to double the risk as compared to total hip arthroplasty. In a study by Lewis et al. regarding timing to diagnosis of surgical site infections in post-hip and knee arthroplasties, the authors found a longer median time to diagnosis post-knee arthroplasty as compared to hip arthroplasty (25 vs. 42 days, p= <0.001). These finding suggest that orthopaedists should recognise that “A knee is not a hip” with regards to surgical site infections and should be aware of the discrepancies that exist between the two

Introduction. Radiation exposure to the eye causes cataracts. Few orthopaedists wear leaded glasses when using fluoroscopy despite regulatory limits for maximum annual eye exposure. Methods. Using anthropomorphic patient and surgeon phantoms, radiation dose at the surgeon phantom's lens was measured with and without leaded glasses during fluroscopic acquisition of 16 common pelvic and hip views. The magnitude of lens dose reduction was calculated by dividing the unprotected dose by the dose measured behind leaded glasses. Results. The unprotected lens dose varied considerably among the different views, ranging from 0 μRem for a single obturator oblique pelvic view, to 257 μRem for a single lateral sacral view with the image intensifier opposite the surgeon. On average, use of leaded glassess reduced radiation to the surgeon phantom's eye by 90%. The greatest reduction was seen with a crosstable lateral radiograph of the hip (22 μRem unprotected lens dose vs. 1 μRem with leaded glasses). Conclusions. The use of leaded glasses could permit an orthopaedist to perform up to 10 times more cases before reaching the annual limit of 20 mSv (20 mSv = 2×10. 6. mRem). A large number of images are often required during a single operative procedure and varies greatly between cases. The number of cases which a surgeon can safely perform without leaded glasses is dependent on the number and type of images, and location of the surgeon with respect to the image intensifier

Introduction. With the widespread legalization of cannabis across the United States, well-powered studies evaluating the impact of cannabis use disorder on outcomes following primary total hip arthroplasty are warranted. Therefore, the aim of this study was to determine whether cannabis use disorder has an effect on patients who undergo primary hip arthroplasty in terms of: 1) hospital lengths of stay (LOS); 2) medical complications; 3) implant-related complications; and 4) costs of care. Methods. Using an administrative database, patients who underwent primary total hip arthroplasty and had cannabis use disorder were matched to a cohort who did not in a 1:5 ratio by age, sex, and various medical comorbidities. This yielded 44,154 patients; 7,361 who had cannabis use disorder and 36,793 who did not. Variables for analysis included postoperative LOS, 90-day medical complications, 2-year implant-related complications, and 90-day costs of care. Mann-Whitney-U tests were used to compare LOS and costs. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of developing complications. A p-value less than 0.005 was considered statistically significant. Results. The study found that patients who had cannabis use disorder had significantly longer in-hospital LOS (4 vs. 3 days, p<0.0001) compared to the matched cohort. Additionally, study patients were found to have significantly higher incidences and odds of developing medical (11.23 vs. 4.82%; OR: 1.47, p<0.0001) and implant-related complications (18.14 vs. 8.60%; OR: 1.50, p<0.0001). Moreover, patients who had cannabis use disorder incurred significantly higher 90-day episode of care costs ($24,585.96 vs. $23,725.93, p<0.0001). Conclusions. With the growing rates of cannabis use, this study can allow orthopaedists and other healthcare professionals to educate cannabis use disorder on the possible outcomes following their total hip arthroplasty. It should be appreciated that cannabis use disorder is associated with longer hospital stays, increased complication rates, and higher costs following primary THA

Introduction and purpose: We present a new decision-making method to assist orthopaedists and radiologists in diagnosing soft-tissue tumours. It can distinguish between benign and malignant characteristics in these lesions and classify them histologically with satisfactory efficiency. The pre-surgical diagnosis of the nature of the tumour and whether it is benign or malignant is crucial to planning surgical procedures. Materials and methods: We reviewed our cases of soft-tissue tumours (47) studied by MRI over the past year and a half. They are part of a multicentre study involving several European hospitals (430 patients). We analysed the clinical and MRI data: age, clinical presentation, size, shape, location, edges, image signal, calcification, intratumour fat, dependency, fibrosis, relation to fascias, bone and vessel disorders. Results: With this method we detected 62% benign tumours and 38% malignant. The system sensitivity and specificity are 86% and 95%, respectively. Conclusions: It is easy to distinguish between vascular, nerve and cystic lesions. The diagnosis of fibrous, synovial and fatty lesions is complex in all cases. The method can help orthopaedists make a diagnosis before surgery, which will facilitate planning of surgical procedures

Purpose: Distal radius fractures are common and rising in incidence as orthopaedists treat an increasingly aged population. Both external fixation and volar plating have demonstrated satisfactory results, however the orthopaedic literature lacks comparative data on radial column plating. The purpose of this prospective study was to compare functional and radiographic data from patients randomized to three surgical modalities – external fixation, volar plating, and radial column plating. Method: This study included 40 patients with closed, unilateral, unstable distal radius fractures distributed as follows: 20 patients treated with external fixation, 10 patients with volar plating, and 10 patients with radial column plating. When classified according to the OTA system, the fractures included types A3, B3, and C1 C3. Patients were followed post-operatively at 2, 4, 6, 12, 24, and 52 weeks. At each visit, patients completed a DASH questionnaire, grip and lateral pinch strength, and range of motion for both wrists. Radiographs were evaluated for lateral tilt, radial inclination, ulnar variance and radial height. Statistical analyses employed single-factor three-way ANOVA of all outcomes at each follow-up period. Results: No significant difference (p> 0.05) was found between mean DASH scores at each follow-up period for all three patient groups. However, each group achieved significant improvement in DASH scores at 1-year follow-up compared to baseline scores (external fixation, p0.05), with final flexion-extension and supination-pronation ranging 78–94% and 92–96% (of the un-injured wrist), respectively. All radiographic measurements demonstrated no significant differences. Reduction was maintained among all three groups without implant failure or complications. Conclusion: At all follow-up periods, analysis of functional and radiographic outcomes showed no significant difference among all groups. Based on this data, no one method of fixation is superior to the others, giving orthopaedists multiple options for surgically reducing the unstable distal radius. Moreover, the diversity in approach of these methods allows additional flexibility in selecting an appropriate technique for each patient

Study Design: A prospective study evaluated patients’, orthopaedists’ and not affected children of the same age ratings’ of preoperative and postoperative cosmesis in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. The cosmetic result based on a questionnaire was compared to clinical and radiological parameters. There was no correlation between the SAQ and objective clinical and radiologic parameters at all, whereas clinical and radiological parameters showed good correlation. We recommend to standardly evaluate the cosmetic outcome as after scoliosis correction surgery. Introduction: Improving cosmesis is an important goal in scoliosis surgery. Patients’ satisfaction with the cosmetic outcome is essential in their evaluation of the surgical result. However, only few efforts were made in the past to investigate the cosmetic outcome. We performed a a prospective study evaluated patients’, orthopaedists’ and not affected children of the same age ratings’ of preoperative and postoperative cosmesis in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. The cosmetic result based on a standardized questionnaire (SAQ, spinal appearance questionnaire) was compared to clinical and radiological parameters. Patient sample: Preoperative and postoperative photographs were taken from 32 patients (22 female, 10 male, average age 14.6 years) preoperatively and postoperatively in a standardized manner. Materials: The photographs were assessed by use of a modified SAQ. In addition radiological measurements were performed like the cobb angles of the main curves in the coronal and sagittal plane, plumb line deviation, shoulder inequality and pelvic obliquity. The clinical investigation included the measurements of shoulder asymmetry, pelvic obliquity, rip and lumbar hump, plumb line deviation, breast asymmetry and the postoperative evaluation of the scar. Results: The items general appearance, body shape, rib hump, and shoulder inequality of the SAQ improved most (p< 0.025). The patients judged the cosmetic result better than surgeons and healthy children (on average: 11 out 15 parameters of the SAQ improved) The surgeons came to the worst judgement (only 5 of 15 parameters improved). The interrater correlation of the surgeons was poor (ICC< 0.58). There was no correlation between the SAQ and objective clinical and radiologic parameters at all, whereas clinical and radiological parameters showed good correlation. Conclusion: As shown in our results objective clinical and radiological parameters do not correlate with the evaluation of the cosmetic result. Therefore we recommend to establish the evaluation of the cosmetic outcome as standard investigation after scoliosis correction surgery

Aims. The aims of this study were to investigate whether 1) multispecialist tertiary intervention for complex spinal pain lead to reductions in spine-related healthcare costs and 2) baseline characteristics are related to health care consuming costs. Patients and methods. A cost study in a natural prospective cohort was carried out to investigate healthcare data of patients admitted to the Groningen Spine Center (GSC) ranging from two years prior to referral until two year after discharge. GSC intervention consisted of a multi-professional and -specialist based diagnosis and treatment. Patients (18 and 80 years) were included, suffering from specific as well as multifactorial spinal pain. Clinical data was merged with Health Care Insurance data and included questionnaires on demographics, work, pain, disability, quality of life and psychosocial functioning. Univariable (paired sample t-tests) and multivariable analyses (pooled OLS Regression and fixed effects models) were carried out. Results. Included were 997 patients (mean age 52 years) filing a total of 700.533 health care declarations. The findings suggest that the intervention had a significant negative effect on spine-related healthcare costs (predominantly on medical specialist and allied care). Reduction in healthcare costs after treatment was predicted by lower age, lower duration, lower BMI, high education, high job satisfaction, low physical workload, high mental health, better coping, lower pain intensity, high EQ-5D score and low financial worries at baseline (all p<0.01). Conclusion. This observational study showed that spine-related healthcare consuming can be effectively reduced after tertiary multi-specialist intervention for patients with complex spinal pain. The results are robust when controlling for background characteristics and are unlikely to be driven by regression to the mean. No conflicts of interest. No funding obtained

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Background. Standard preoperative protocols in total joint arthroplasty utilize the International Normalized Ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Acceptable INR cutoff values for joint replacement are inconsistent, and are often based on studies of primary arthroplasty, or even non-orthopedic procedures. This analysis examined the relationship between preoperative INR values and post-operative outcomes in revision total hip arthroplasty (rTHA). Optimal cutoff INR values correlated with specific outcomes were subsequently determined. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was retrospectively queried for revision total hip arthroplasty procedures performed between 2006 and 2017. Patients with a preoperative INR collected no later than 1 day prior to surgery were further stratified for analysis. INR values which correlated with specific outcomes were determined using receiver operating characteristics (ROC) curves for each outcome of interest. The optimal cutoff INR value for each outcome was then obtained using univariate and multivariate models which determined INR values that maximized both sensitivity and specificity. Results. There were a total of 11,393 patients who underwent a revision total hip arthroplasty from 2006–2017 recorded in NSQIP. Of the 2,012 patients who met inclusion and exclusion criteria, 858 had an INR < 1.0, 931 had an INR > 1.0 to 1.25, 175 had an INR > 1.25 to 1.5, and 48 patients had an INR > 1.5. Patients with progressively higher INR values had a significantly different risk of mortality within 30 days (p=0.005), bleeding requiring transfusion (p< 0.001), sepsis (p=0.002), stroke (p<0.001), failure to wean from ventilator within 48 hours (p=0.001), readmission (p=0.01), and hospital length of stay (p< 0.001). Similar results were obtained when utilizing optimal INR cutoff values. When correcting for other factors, the following poor outcomes were significantly associated with the respective INR cutoff values (Estimate, 95% CI, p value): LOS (1.67, 1.34–2.08, p <0.001), bleeding requiring transfusion (1.65, 1.30–2.09, p<0.001), sepsis (2.15, 1.11–4.17, p 0.02), and any infection (1.82, 1.01–3.29, p 0.04). Conclusions. INR values >1.65, >1.67, >1.82, and >2.15 were correlated with increased transfusion requirements, LOS, any infection, and sepsis respectively. Therefore, even subtherapeutic elevations in INR may predict poor outcomes following revision total joint replacement. Surgeons and perioperative medical specialists should consider more stringent INR goals when optimizing patients prior to revision arthroplasty. Level of Evidence. Prognostic Level IV. For any figures or tables, please contact authors directly

Patients who have multiple sclerosis (MS) may be at increased risk of developing complications after total hip arthroplasty (THA). The purpose of this study was to compare: 1) implant survivorship; 2) functional outcomes; 3) complication rates; and 4) radiographic findings after THA between MS patients and a matched cohort. A single institutional database was reviewed for patients who had a diagnosis of MS and underwent a THA. Thirty-four patients (41 hips) were matched to a 2:1 cohort who did not have MS using based on age, sex, body mass index (BMI), and Charlson/Deyo scores. This resulted in a matching cohort of 80 patients (82 hips). The available medical records were reviewed. Functional outcomes and complications were assessed. Postoperative radiographs were evaluated. The matching cohort had higher all-cause survivorship at 4-years postoperatively (99 vs. 93%). There were 3 revisions in the MS cohort and 0 revisions in the matching cohort. The MS cohort had lower mHHS scores (66 vs.74 points, p<0.001), lower HOOS JR scores (79 vs. 88 points, p<0.01), required more physical therapy (5 vs. 3 weeks, p<0.01), and took longer to return to their baseline functional level (7 vs. 5 weeks, p<0.05). MS patients had higher rate of complications (6 vs. 1, p<0.05). Excluding revision cases, there was no additional radiographic evidence of progressive radiolucency, loosening, or subsidence. We found that MS patients had lower implant survivorship, lower functional outcome scores, and increased complication rates. These findings may help orthopaedists to have a better knowledge of how MS patients do after THA

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.