Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Wide resection, with or without adjuvant therapy, is the mainstay of treatment for soft tissue sarcoma of the extremities. The surgical treatment of soft tissue sarcoma can portend a prolonged course of recovery from a functional perspective. However, data to inform the expected course of recovery following sarcoma surgery is lacking. The purpose of this study was to identify time to maximal functional improvement following sarcoma resection and to identify factors that delay the expected course of recovery. A retrospective chart review was performed of all patients undergoing surgical treatment of a soft tissue sarcoma of the extremities between January 1st, 1985 and November 15, 2020 with a minimum of 1 follow up. The primary outcome measure was time to maximal functional improvement, defined as failure to demonstrate improvement on two consecutive follow up appointments, as defined by the functional outcome measures of Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) Score or by achieving 90% of maximum outcome score. We identified 1188 patients who underwent surgical resection of a soft tissue sarcoma of the extremities. Patients typically achieved a return to their baseline level of function by 1 year and achieved “maximal” functional recovery by 2 year's time postoperatively. Patient and tumor factors that were associated with worse functional outcome scores and a delayed return to maximal functional improvement included older age (p=0.007), female sex (p-0.004), larger tumor size (p < 0 .001), deep tumor location (p < 0 .001), pelvic location (p < 0 .001), higher tumor grade (p < 0 .001). Treatment factors that were associated with worse functional outcome scores and a delayed return to maximal functional improvement included use of radiation therapy (p < 0 .001), perioperative complications (p < 0 .001), positive margin status (p < 0 .001) and return of disease, locally or systemically (p < 0 .001). Most patients will recover their baseline function by 1 year and achieve “maximal” recovery by 2 years’ time following surgical resection for soft tissue sarcoma of the extremities. Several patient, tumor and treatment factors should be used to counsel patients as to a delayed course of recovery

Short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients, mainly due to its bone preserving philosophy. Elderly patients, however, may also benefit of a minimally invasive technique due to the short and curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young (75 years) population. Data were collected in a total of 5 centers, and 400 short stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Clinical and radiological outcomes were assessed in both groups. Secondary outcomes such as perioperative complications, rates and reasons for stem revision were also investigated. No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction. Harris Hip Score (HHS) was found to be slightly better in the young group. Comparing both groups, no statistically significant differences ere found in the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis). Aseptic loosening was the main cause of implant failure in younger patients whereas in elderly patients, postoperative periprosthetic fractures due to accidental fall was found to be the main cause for stem revision. These short-term results are encouraging towards the use of a cementless short stem in the geriatric population. According to our findings, advanced age and potentially reduced bone quality should not necessarily be considered as contra-indications for calcar-guided short-stem THA but careful and reasonable selection of the patients is mandatory. Longer follow up is necessary in order to draw safer conclusions

Objectives. Tranexamic acid (TXA), an inhibitor of fibrinolysis blocking the lysine-binding site of plasminogen to fibrin, has been reported to reduce intraoperative and postoperative blood loss in patients undergoing primary total hip arthroplasty (PTHA) both with and without cement. Both intravenous (IV) and topical (TOP) administration of TXA can effectively reduce blood loss in THA without increasing risk of deep venous thrombosis (DVT). However, there have been few reports investigating the combination of intravenous and topical administration of TXA in bilateral cementless PTHA. We investigated the effects of combined intravenous and topical administration of TXA on postoperative blood loss, drainage volume, and perioperative complications in patients with bilateral simultaneous cementless PTHA for hip osteoarthritis. Patients and methods. We retrospectively reviewed the demographic and clinical data of 41 patients who underwent bilateral simultaneous cementless PTHA for hip osteoarthritis from May 2015 to January 2017, of which there were 29 male (70.7%) and 12 female (29.3%) patients. Patients in IV group (n= 11) received only TXA (15 mg/kg) 10 min prior to the incision of each side; and patients in IV + TOP group (n=13) received i.v. TXA (15 mg/kg) combined with topical adiministration (1.0 g) of TXA during the each THA procedure; patients in control group (n=17) received the same dosage of normal saline both i.v. and topically. Outcome measures were total blood loss, hemoglobin, hematocrit value (HCT) changes preoperatively, and on the 1st, 3rd postoperative day, the amount of drainage, and perioperative complications. Results. On the 1st, 3rd postoperative day, patients in group IV and group IV + TOP had significantly higher haematological parameters (haemoglobin, hematocrit value (HCT)) than patients in control group (P < 0.05 (group IV vs control group), P < 0.01 (group IV + TOP vs control group), respectively), while no significant differences found between patients in group IV and group IV + TOP (P > 0.05). The postoperative drainage volume of patients in group IV and group IV + TOP were significantly less than those in control group (P < 0.01, P < 0.01, respectively), while no significant differences found between those in group IV and group IV + TOP (P > 0.05). No significant differences were found in the perioperative complications (DVT or PE) among all three groups. Conclusion. The combined administration of intravenous and topical TXA resulted in a significantly reduction in postoperative blood loss, compared with placebo group. No adverse perioperative complications were observed. This study supports the combined intravenous and topical administration of TXA in bilateral cementless PTHA

Obesity is an increasing public health concern associated with increased perioperative complications and expense in lumbar spine fusions. While open and mini-open fusions such as transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF (MIS-TLIF) are more challenging in obese patients, new MIS procedures like oblique lateral lumbar interbody fusion (OLLIF) may improve perioperative outcomes in obese patients relative to TLIF and MIS-TLIF. The purpose of this study is to determine the effects of obesity on perioperative outcomes in OLLIF, MIS-TLIF, and TLIF. This is a retrospective cohort study. We included patients who underwent OLLIF, MIS-TLIF, or TLIF on three or fewer spinal levels at a single Minnesota hospital after conservative therapy had failed. Indications included in this study were degenerative disc disease, spondylolisthesis, spondylosis, herniation, stenosis, and scoliosis. We measured demographic information, body mass index (BMI), surgery time, blood loss, and hospital stay. We performed summary statistics to compare perioperative outcomes in MIS-TLIF, OLLIF, and TLIF. We performed multivariate regression to determine the effects of BMI on perioperative outcomes controlling for demographics and number of levels on which surgeries were operated. OLLIF significantly reduces surgery time, blood loss, and hospital stay compared to MIS-TLIF, and TLIF for all levels. MIS-TLIF and TLIF do not differ significantly except for a slight reduction in hospital stay for two-level procedures. On multivariate analysis, a one-point increase in BMI increased surgery time by 0.56 ± 0.47 minutes (p = 0.24) in the OLLIF group, by 2.8 ± 1.43 minutes (p = 0.06) in the MIS-TLIF group, and by 1.7 ± 0.43 minutes (p < 0.001) in the TLIF group. BMI has positive effects on blood loss for TLIF (p < 0.001) but not for OLLIF (p = 0.68) or MIS-TLIF (p = 0.67). BMI does not have significant effects on length of hospital stay for any procedure. Obesity is associated with increased surgery time and blood loss in TLIF and with increased surgery time in MIS-TLIF. Increased surgery time may be associated with increased perioperative complications and cost. In OLLIF, BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between obese and non-obese patients

Introduction. Reverse shoulder Arthroplasty is a successful treatment for gleno-humeral osteoarthritis. However, components loosening and painful prostheses, related to components wrong positioning, are still a problem for those patients who underwent this kind of surgery. Several new technology has been developed the improve the implant positioning. CT-based intraoperative navigation system is a suitable technology that allow the surgeon to prepare the implant site exactly as planned with preoperative software. Method. Thirty reverse shoulder prostheses were performed at Modena Polyclinic using GPS CT-based intraoperative navigation system (Exactech, Gainsville, Florida). Walch classification was used to assess glenoid type. Planned version and inclination of the glenoid component, planned seating, final version and inclination of the reamer were recorded. Intraoperative and perioperative complication were recorded. Planned positioning was conducted aiming to the maximum seating, avoiding retroversion >10° and superior inclination. Results. Eight patients were male, 22 were female. Mean age was 75 years old (range 58–87). 4 glenoid were type B3, four were B2, 10 cases were B1, 12 case were A1/A2. Posterior or superior augment was used in 15 cases. Mean planned seating was 93%. Mean preoperative version was -7.5±6.9°; Mean planned version was -2±2.8°; Mean intraoperative measured version was -1.9±2.8°; no statistical difference was found between planned and intraoperative version (p=0.16). Mean preoperative inclination was 1.8±6.°; Mean planned inclination was -2.2±2.4°; Mean intraoperative measured inclination was -2.1.9±2.3°; no statistical difference was found between planned and intraoperative version or inclination (respectively p=0.16 and p=0.32). Mean surgical time was 71 minute (range 51–82). Three cases of coracoid ruptures were reported, 1 failure of the system occurred. Discussion. GPS navigation system allows the surgeon to prepare the implant site as planned on Preoperative software in Reverse shoulder arthroplasty, with no statistical difference between planned orientation and intraoperative measured orientation. That means that even in the most difficult cases the surgeon is able to find a good positioning (93% seating)and to replicate it in the operative room. Only one failure of the system occurred, because too much time was passed between CT scan and surgery (9 months). Three coracoid fractures occurred in the first 10 cases: these could be addressed to a lack of confidence with the double lateralization of this prosthesis which increase tensioning on the coracoid and a lack of confidence in tracker positioning, which should be made as proximal as it is possible. Finally, the system needs several improvements to be considered a breakthrough technology, such as humeral component positioning and final control of the implant, but by now is a useful way to improve our surgery, especially in difficult cases

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at considerably increased risk of perioperative complications. Therefore, strategies to assist patients with smoking cessation before surgery have become routine practice. A secondary benefit is the theoretical catalyst for long-term smoking cessation. However, questions remain as to whether patients actually cease smoking prior to the procedure, and if so, how long this lasts postoperatively. Our high-volume, academic institution documents self-reported smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through a total joint registry. As such, all patients who underwent TJA from 2007 to 2018 were identified and grouped as: non-smokers, smokers (regularly smoking cigarettes within 1 year from surgery), and former smokers (those who quit smoking within a year before surgery). Thereafter, smoking status in the postoperative period was assessed, with special attention to the former smokers in order to see who remained smoke-free. From the 28,758 primary TJAs identified, 91.3% (26,244) were non-smokers, 7.3% (2,109) were smokers, and 1.4% (405) had quit smoking before surgery. Among patients who quit smoking before surgery, only 38% were still abstinent at 9 years from surgery. Conversely, 24% of smokers at the time of surgery eventually quit and 3.1% of non-smokers started smoking over the same time period. Despite a concerted effort to help patients stop smoking before TJA, an important proportion (7.3%) are unsuccessful. Among those patients who do manage to stop smoking, only a minority (38%) remain smoke-free after surgery. Compared to current smokers, patients who managed to quit before surgery are more likely to remain smoke-free after surgery. These findings highlight that smoking remains a tremendous challenge in contemporary TJA practices. Additional strategies targeting smoking cessation before after surgery are needed

Surgical fixation of tibial plateau fractures in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared to younger patients. Primary total knee arthroplasty (TKA) may be of benefit in patients with pre-existing arthritis, marked osteopenia, or severe fracture comminution. Rationale for primary TKA includes allowing early mobility in hopes of reducing associated complications such as deconditioning, postoperative pneumonia, or venous thromboembolism, and reducing post-traumatic arthritis which occurs in 25% to 45% of patients and requires revision TKA in up to 15%. Subsequent revision TKA has been shown to have significantly worse outcomes than TKA for primary osteoarthritis. This systematic review sought to elicit the clinical outcomes and peri-operative complication rates following primary TKA for tibial plateau fractures. A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and clinical outcomes following primary TKA for tibial plateau fractures. Studies were included for final data analysis if they met the following criteria: (1) studies investigating TKA as the initial treatment for tibial plateau fractures, (2) patients must be ≥ 18 years old, (3) have a minimum ≥ 24-month follow-up, and (4) must be published in the English language. Case series, cohort, case-control, and randomized-control trials were included. Weighted means and standard deviations are presented for each outcome. Seven articles (105 patients) were eligible for inclusion. The mean age was 73 years and average follow-up was 39 months. All-cause mortality was 4.75% ± 4.85. The total complication rate was 15.2% ± 17.3% and a total of eight patients required revision surgery. Regarding functional outcomes, the Knee Society score was most commonly reported. The average score on the knee subsection was 85.6 ± 5.5 while the average function subscore was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5° ± 10°. Total knee arthroplasty for the treatment of acute tibial plateau fractures is enticing to allow early mobility and weightbearing. However, complication rates remain high. Functional outcomes are similar to patients treated with ORIF or delayed arthroplasty. Given these findings, surgeons should be highly selective in performing TKA for the immediate treatment of tibial plateau fractures

Malnutrition is often associated with the advanced age and can be influenced by physical, mental, social and environmental changes. Hip fracture is a major issue and a prior poor nutritional status is associated with higher rates of perioperative complications and prolonged hospital length of stay. Prospective observational cohort study performed in a Level one trauma center including 189 consecutive patients admitted for hip fracture. The main outcome measure was the Mini Nutritional Assessment (MNA), a specific tool validated for geriatric population. This questionnaire was performed at admission by an independent assessor, at the same time as a large set of demographic and functional data. Blood samples were tested for blood count and albuminemia. Two groups were constituted and analysed according to a MNA score ≥ 24 (lower limit for normal nutritional status). Factors explored included physical and mental items. Impact of malnutrition was determined on hospital length of stay (HLS), discharge in an adverse location than prior to admission (DAL), complications and mortality rate. The rate of patients with malnutrition (or at risk) in this study is 47% (88 patients). Patients with a MNA < 24 are older (84.81 yrs ± 7.75 vs 80.41 ± 8.11, p<0,01), have more comorbidities (Charlson 2.8 ± 2.21 vs 1.67 ± 3.10, p<0,01), a more impaired mental (MMSE 19.39±8.55 vs 25.6±3.6, p<0,01) or physical status (MIF 105.3 ± 26.6 vs 121.8 ± 6.4, p< 0,01). Blood samples are not selective to detect malnutrition (p=0,64). Malnutrition is associated with a longer HLS (26.04±23.39 days vs 13.95±11.34 days, p<0,01), a greater DAL (58.9% vs 38.2%, p=0,02) and a higher one year mortality rate (23.9% vs 8.9 %, p<0,01). The prevalence of malnutrition in a geriatric population admitted for hip fracture is high. Blood samples at admission have clearly a poor value and a systematic screening with the MNA is mandatory. An early diagnosis will target specific interventions to reduce the physical and socio-economic impact of the malnutrition. Future studies should focus on actions in the perioperative stage (fast-track surgery, nutritional protocols, analgesia) and their impact on the socio-economic burden

Intrathecal morphine (IM) is a common adjunct in paediatric spinal deformity surgery. We previously demonstrated with idiopathic scoliosis it provides safe and effective analgesia in the immediate postoperative period. This study represents our 25 year experience with IM in all diagnostic groups. Our prospective Pediatric Orthopaedic Spine Database (1993–2018) was reviewed to identify all patients undergoing spinal deformity surgery who received IM and who did not. Patients 21 years of age or less who had a posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI), and received 9–19 mcg/kg (up to 1 mg) of IM were included. Early onset scoliosis surgical patients were excluded. We assessed demographics, pain scores, time to first dose of opioids, diagnoses, surgical time, paediatric intensive care unit (PICU) admission and IM complications (respiratory depression, pruritus, nausea/ vomiting). There were 986 patients who met inclusion criteria. This included 760 patients who received IM and 226 who did not. IM was not used for short procedures (< 3 hrs), respiratory concerns, unsuccessful access of intrathecal space, paraplegia, and anesthesiologist decision. Both groups followed the same strict perioperative care path. The patients were divided into 5 diagnostic groups (IM / non IM patients): idiopathic (578/28), neuromuscular (100/151), syndromic (36/17), and congenital scoliosis (32/21) and kyphosis (14/9). Females predominated over males (697/289). The first dose of opioids after surgery was delayed for a mean of 10.6 hrs in IM group compared to 2.3 hrs in the non-IM group (p=0.001). The postoperative pain scores were significantly lower in the IM groups in the Post Anesthesia Care Unite (p=0.001). Only 17 IM patients (2%) were admitted to the PICU for observation secondary to respiratory depression, none required re-intubation. None of the IM group were re-intubated. Forty-nine patients (6%) experienced pruritus in the IM group compared to 4 of 226 patients (2%) in the non IM group. There were 169 patients (22%) of the IM patients and 21 patients (9%) of the non IM had nausea and vomiting postoperatively. Three patients (0.39%) had a dural leak from the administration of IM but did not require surgical repair. There were no other perioperative complications related to the use of IM. There were no significant group differences. Pre-incision IM is a safe and effective adjunct for pain management in all diagnostic groups undergoing spinal surgery. The IM patients had lower pain scores and a longer time to first administration of post-operative opioids. Although there is an increased frequency of respiratory depression, pruritus, and nausea/vomiting in the IM group, there were no serious complications

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis. The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts. Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care). General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates

Background. Fifteen to twenty percent of patients presenting for total hip arthroplasty (THA) have bilateral disease. While simultaneous bilateral THA is of interest to patients and surgeons, debate persists regarding its merits. The majority of previous reports on simultaneous bilateral THA involve patients in the lateral decubitus position, which require repositioning, prepping and draping, and exposure of a fresh wound to pressure and manipulation for the contralateral THA. The purpose of this study was to compare complications, component position, and financial parameters for simultaneous versus staged bilateral THAs using the direct anterior approach (DAA). Methods. Medical records were reviewed for patient demographics, medical history, operative time, estimated blood loss (EBL), change in hemoglobin, transfusion, tranexamic acid (TXA) use, length of stay (LOS), discharge disposition, leg length discrepancy, acetabular cup position, and perioperative complications. Cost and reimbursement data were analyzed. Results. Forty-four patients were included in the sequential group and fifteen patients in the simultaneous group (Figure 1). Operative time was significantly longer for simultaneous DAA THA, with procedures lasting 260 +/− 48 minutes compared to 132 +/− 30 minutes for a single arthroplasty in the sequential group (p<0.001). Patients undergoing simultaneous bilateral DAA THA also had a significantly higher EBL (p<0.001), hemoglobin drop (p<0.001), and blood transfusion rate (p<0.01) compared to parameters for a single arthroplasty in the sequential group. This was despite TXA being used in a significantly higher proportion of simultaneous procedures compared to sequential procedures (p<0.01). The LOS was significantly longer in patients undergoing simultaneous bilateral DAA THA (2.9 +/− 1.0 days) compared to sequential (2.2 +/− 0.6 days) (p<0.001). No deep venous thrombosis (DVT) or pulmonary embolism (PE) was detected in either group during the observation period. No significant difference was detected regarding perioperative complications or whether patients were able to be discharged home instead of to a post-inpatient facility (Figure 2). There was no significant difference in component position, complications, or readmissions between groups. Total cost per hip was significantly less for the simultaneous ($15,565 +/− 1,470) compared to the sequential group ($19,602 +/− 3,094) (p<0.001). There was no significant difference in total payments between the simultaneous group ($25,717 +/− 4,404) and the sequential group ($24,926 +/− 8,203) (p=0.93). Thus, with lower cost and similar reimbursement, profit per hip was significantly higher for the simultaneous ($9,606 +/− 5,060) compared to the sequential group ($5,324 +/− 7,997) (p<0.05). (Figure 3). Conclusions. Significant data regarding simultaneous bilateral THA has been published but results are conflicting and different surgical approaches were used. To our knowledge only four previous reports have been published examining simultaneous bilateral THA performed via the DAA. While simultaneous DAA THA presents challenges, our results suggest that simultaneous DAA THA may add value to the healthcare system without resulting in increased complications compared to sequential hip arthroplasty

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Introduction. Total shoulder replacement is a successful treatment for gleno-humeral osteoarthritis. However, components loosening and painful prostheses, related to components wrong positioning, are still a problem for those patients who underwent this kind of surgery. CT-based intraoperative navigation system is a suitable option to improve accuracy and precision of the implants as previously described in literature for others district. Method. Eleven reverse shoulder prostheses were performed at Modena Polyclinic from October 2018 to April 2019 using GPS CT-based intraoperative navigation system (Exactech, Gainsville, Florida). In the preoperative planning, Walch classification was used to assess glenoid type. The choice of inclination of the glenoid component, the screw length, as well as the inclination of the reamer was study and recorded using specific software using the CT scan of shoulder of each patient (Fig.1, Fig.2). Intraoperative and perioperative complications were recorded. Three patients were male, eight were female. Mean age was 72 years old (range 58=84). Three glenoid were type B2, six cases were B1, two case were type C1. Results. In all cases treated by reverse shoulder prostheses we had obtain good functional results at preliminary follow up. Eight degree posterior augment was used in seven case. Planned version was 0° in eight case, an anti-version of 3° was planned in the other three cases. Final reaming was as preoperatively planned in all cases except one. Mean surgical time was 71 minutes (range 51–82). One case of coracoid rupture has been reported. In all cases the system worked in proper manner without failures, no case of infection was reported. Discussion. It is well known as the more accurate placement of the glenoid led to enhanced long-term survivorship of the implant and decrease complication rates in RSTA. Our first experience with GPS navigation system has been satisfied. Good components’ positioning has been reached in all cases, without deviation from the preoperative planning. Pre-operative preparation using software has been always respected except in one case in which we decided to ream 1mm less to avoid excessive bone loss. In 3 case we decide to increase glenoid anti-version to allow a good cage containment in the scapula. No failure of the system has been recorded, with a little increase in the surgical time respect to traditional surgeries performed in our institute. The first case performed reported coracoid fracture, probably due to lack of experience in coracoid tracker positioning. It is very important to set the surgical theatre and the position of the patient in order to make the coracoid tracker visible for the computer. Screw positioning and length is decisively improved with GPS system compared with traditional implant. The most important advantage is to avoid the malposition of the glenoid component, solving problems like loosening or restriction in shoulder range of motion. We believe that a final cross check between preoperative planning and final control of the prostheses implanted, should be used in the future, but by now the GPS navigation system is a useful way to improve our surgery, especially in difficult cases. For any figures or tables, please contact the authors directly

Total Knee Arthroplasty (TKA) in obese patients has been under rigorous scrutiny due concerns of less satisfying results and increased risk of perioperative complications. We conducted a prospective study to observe functional scores between obese and non obese patients at two years after mini-robot computer assisted TKA. Average stay, time for wound to be dry and perioperative complications were also compared. A prospective study was conducted between February 2007 and February 2008 involving 50 patients. Two different groups of 25 each were made on the basis of body mass index (BMI). Oxford and Knee society scores were obtained at two years to observe difference in functional scores between these groups. Rate of post operative complications or hospital stay was comparable between the two groups. Oxford and Knee society scores improved significantly in both the groups postoperatively. Obese patients had better Oxford and Knee society scores, which were not statistically significant. There is no difference in early functional outcome and complications between obese and non obese patients after navigated TKA. Navigated TKA in obese patients help precise component placement with appropriate soft tissue balancing leading to improved results

Background:. A large percentage of the patients who present for unilateral TKA have bilateral disease. Performing simultaneous, bilateral TKA has been debated and currently there is no consensus on the risks and benefit of this approach. In addition, specific selection criteria have not been defined to more accurately identify which patients are potentially appropriate candidates for this approach. Objectives:. The purpose of this study was to evaluate the clinical outcomes and peri-operative complications in simultaneous, bilateral TKA's using pre-operative patient selection criteria. Methods:. A retrospective analysis of 117 consecutive patients, (234 knees), was performed between February 2008 and March 2012 who underwent simultaneous, bilateral TKA performed by one surgeon under a single anesthetic. Pre-operative selection criteria were used for all patients to qualify for a simultaneous bilateral approach. This included the following: . 1). BMI less than 34,. 2). Minimum arc of motion to 100 degrees flexion,. 3). Flexion contracture less than 10 degrees,. 4). Varus or valgus alignment less than 10 degrees,. 5). No prior history of cardiovascular disease. 6). Age Less than 70 years old. Clinical outcomes were assessed including anesthesia type, tourniquet time, length of stay, transfusion rate, pre- op hemoglobin, post-op hemoglobin, pre-op range of motion, post-op range of motion, DVT and PE. Knee Society Score (KSS) and Functional KSS were assessed pre-operatively and 1 year post-operatively. Anatomic and mechanical axis evaluation was also performed on all patients with long standing radiographs pre and post operatively. A control group of 573 consecutive patients undergoing unilateral total knee arthroplasty during this same time period were identified and matched for the year of surgery, and prosthesis type. The same selection criteria were used for the control group and the same data points were evaluated. Results:. One hundred and seventeen consecutive patients, (234 knees), undergoing simultaneous, bilateral TKA were reviewed. There were no DVT's, or PE's. Nineteen percent required a transfusion for post-operative anemia. There were no cases of deep infection. Average pre-op KSS score was 49, with a post KSS score of 89 at an average follow-up of 1 year. Average pre-op Functional KSS score was 52, with an average post-op Functional KSS score of 91. Average ROM at one year post-op was 0 degrees of extension and 123 degrees of flexion. Average anatomic axis was 6 degrees valgus with a neutral mechanical axis restored in all patients. The clinical outcomes of the control group were comparable, with no statistically significant increase in the incidence of perioperative complications between the study group and the control group. Conclusion:. When the degenerative process involves both knees with comparable severity, the decision to perform total knee arthroplasty on one knee at a time with a staged approach, verses a simultaneous bilateral approach, has been challenging for many surgeons. There have been previous reports of increased perioperative complications associated with bilateral total knee arthroplasty, including increased risks of cardiovascular, neurological complications, as well as the increased demands on rehabilitation. Similarly, benefits of simultaneous bilateral total knee arthroplasty have also been identified such as, shortened rehabilitation, improved patient satisfaction, and decreased costs both to the patient and the hospital system. Using pre-operative patient selection criteria, the decision process in determining which patients are appropriate candidates for a bilateral approach can be facilitated, with clinical outcomes comparable to unilateral total knee arthroplasty

It is estimated that approximately 3.1 – 7.7% of the general population suffers from primary osteoarthritis of the hip, with up to 42% of these cases being bilateral. The odds of undergoing a contralateral THA after index unilateral THA range from 16–85%. Up to 20% of these patients have the contralateral THA within 5 years. For this patient population, simultaneous bilateral THA may be an appealing option but it remains controversial. Proponents of bilateral simultaneous THA cite advantages such as a single anesthetic exposure, overall shorter length of hospital stay, quicker recovery, earlier return to function, less time off of work, and potential economic advantages. Only recently has there been more data emerging on patients undergoing simultaneous bilateral THA through the direct anterior approach (DAA). The DAA has the distinct advantage of supine positioning that facilitates easy exposure to both hips without the need to reposition the patient onto a fresh surgical incision while performing the second operation. Recent publications suggest that bilateral simultaneous DAA is a safe procedure and may have economic benefits as well. At our institution between 2010 and 2016, a consecutive series of 105 patients (210 hips) undergoing simultaneous bilateral DAA THA and a matched group of 217 patients undergoing unilateral DAA THA by the same surgeon at a single institution were reviewed. The two groups were matched by gender, age, body mass index and date of surgery. There were no significant differences between the two groups in terms of early complications. There were 2 complications in the unilateral group that were intraoperative nondisplaced calcar fractures that were treated with a single cerclage cable and 50% weight bearing for four weeks. There were 6 in-hospital systemic complications in the unilateral group compared to 7 in the bilateral group (p = 0.129). In-hospital systemic complications were similar between the two groups and included urinary retention, cardiopulmonary abnormalities, alcohol withdrawal, and nausea / vomiting. There were a total of 14 30-day follow-up hip-related complications in the unilateral group compared to 5 in the bilateral group (p = 0.06) These complications were similar between the two groups and included wound healing issues, tendinitis / bursitis, deep infection, nerve palsy, stem subsidence, and instability. Intraoperative estimated blood loss (EBL) was 360cc in the unilateral group compared to 555cc in the bilateral group (p < 0.001). The bilateral group had lower postoperative day one (POD1) hemoglobin (9.5 g/dl vs. 10.2 g/dl; p < 0.001). Four percent of unilateral patients required blood transfusion compared to 11% in the bilateral group. There were significant differences between the two groups in terms of distance ambulated on POD1 and length of stay (LOS). On average, the unilateral patients walked 235 feet on POD1 compared to 182 feet for the bilateral patients (p < 0.001). Length of stay was significantly longer in the bilateral group (1.95 days vs. 1.12 days; p < 0.001). All 322 patients involved in the study were discharged to home except for a single patient in the bilateral group who was discharged to a skilled nursing facility. In conclusion, we found no difference in in-hospital or 30-day complication rates when comparing the simultaneous bilateral group to the unilateral group. The main difference when compared to unilateral surgery is increased blood loss yet this did not directly result in specific complications. Simultaneous bilateral DAA THA can be performed safely and without an unacceptably high perioperative complication rate

An increasing number of patients with hepatitis B virus (HBV) infection are progressing in age and are undergoing total joint arthroplasty (TJA) surgery in China. Less attention is provided to the special populations. This study aimed to evaluate the effect of HBV on TJAs. We retrospectively reviewed all patients who met the inclusion of undergoing elective primary hip and knee arthroplasties from 2013– 2016. Non-hepatitis B cohort was built to match the case cohort to identify whether HBV infection was a risk factor associated with postoperative complications. A total number of 197 patients who underwent primary TJAs were involved in the study, including 49 patients with hepatitis B and 147 non-hepatitis B subjects. Among all the patients with TJAs, we obtained a 5.5% HBV infection rate for the first time. Compared with patients without hepatitis B, patients with hepatitis B had higher rates (P < 0.01) of total complications (10.2% compared to 4.7%), surgery-related complications (6.1% compared to 3.4%), and general medical complications (4.1% compared to 1.3%) than the non-hepatitis B group. Patients with hepatitis B infection had a 21% increased risk (95% CI, 0.97–1.46; p < 0.01) of total complication compared with non-hepatitis B group. Similar results were obtained for medical and surgical complications. HBV infection had a 31% increased risk (95% CI, 1.02–1.62; p < 0.01) for medical complication and 18% risk (95% CI, 0.95–1.42; p < 0.01) for surgical complication. In the subgroup analysis, no difference was found between the surgical methods and sex, whereas a significant difference of CRP change level (P < 0.01) was found between HBV group and the matched group in the clinical laboratory values. This is the first study of patients with hepatitis B undergoing primary THA or TKA and demonstrates an increased risk of multiple perioperative complications in a Chinese population. In consideration of the large population of HBV infection in China, more attention should be provided to patients with HBV infection who need to undergo TJAs