Introduction. The acetabular cup should be properly oriented to prevent dislocation and to reduce wear and leg length discrepancy. Despite advances in surgical techniques and instrumentation, achieving proper cup placement in total hip arthroplasty (THA) is challenging with potentially large variations of cup position and limited accuracy. We evaluated whether cup placement on anatomical location ensured original center of rotation (COR) and surgeon's experiences of THA reduced variations in acetabular component positioning. Methods. We retrospectively reviewed 145 patients (145 hips) of unilateral THAs with normal contralateral structures of acetabulum and femoral head. All surgeries were performed using the modified posterolateral approach that preserves short external rotator muscles. All of the 145 THAs were performed by two surgeons, who were in the same teaching hospital, but had differences in
Background. The current literature tends to suggest that all the different approaches used for Knee Arthroplasty give similar results. The literature also cautions that the MINI quadriceps sparing approaches are to be utilized in very select cases as they are difficult to perform, take longer time, have a greater intra-op complication rate and are associated with a higher number of component malpositioning. Despite these warnings of the literature, the author has been impressed by the physiological nature of the subvastus approach for knee arthrotomy and the author has used this approach exclusively for all Knee arthroplasties in the last 4 years. All primary Knee Arthroplasties have been performed through the mini-subvastus approach, utilizing the principle of a mobile window, irrespective of the degree of pre-operative deformity, obesity, range of motion or previous surgery. All revision Knee Arthroplasties have also been performed through the subvastus approach. All the surgeries have been performed in the private sector in a highly competitive environment with the patient having easy access to various other high volume surgeons performing arthroplasties through a more standard approach. Aim. To define the place of the subvastus approach in Knee arthroplasty on the basis of
Malpositioning of the tibial component is a common error in TKR. In theory, placement of the tibial tray could be improved by optimization of its design to more closely match anatomic features of the proximal tibia with the motion axis of the knee joint. However, the inherent variability of tibial anatomy and the size increments required for a non-custom implant system may lead to minimal benefit, despite the increased cost and size of inventory. This study was undertaken to test the hypotheses:
That correct placement of the tibial component is influenced by the design of the implant. The operative experience of the surgeon influences the likelihood of correct placement of contemporary designs of tibial trays. CAD models were generated of all sizes of 7 widely used designs of tibial trays, including symmetric (4) and asymmetric (3) designs. Solid models of 10 tibias were selected from a large anatomic collection and verified to ensure that they encompassed the anatomic range of shapes and sizes of Caucasian tibias. Each computer model was resected perpendicular to the canal axis with a posterior slope of 5 degrees at a depth of 5 mm distal to the medial plateau. Fifteen joint surgeons and fourteen experienced trainees individually determined the ideal size and placement of each tray on each resected tibia, corresponding to a total of 2030 implantations. For each implantation we calculated: (i) the rotational alignment of the tray; (ii) its coverage of the resected bony surface, and (iii) the extent of any overhang of the tray beyond the cortical boundary. Differences in the parameters defining the implantations of the surgeons and trainees were evaluated statistically.Introduction
Materials and Methods
Introduction. With advances in mobile application, digital health is being increasingly used for remote and personalised care. Patient education, self-management and tele communication is a crucial factor in optimising outcomes. Aims. We explore the use of a smartphone app based orthopaedic care management system to deliver personalised
The Australia and New Zealand Sarcoma Association established the Sarcoma Guidelines Working Party to develop national guidelines for the management of Sarcoma. We asked whether surgery at a specialised centre improves outcomes. A systematic review was performed of all available evidence pertaining to paediatric or adult patients treated for bone or soft tissue sarcoma at a specialised centre compared with non-specialised centres. Outcomes assessed included local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival. Definitive surgical management at a specialised sarcoma centre improves local control as defined by margin negative surgery, local or locoregional recurrence, and local recurrence free survival. Limb conservation rates are higher at specialised centres, due in part to the depth of
Aim. There is a constant increase of total joint arthroplasties to improve the quality of life of an aging population. Prosthetic-joint infections are rare, with an incidence of 1–2%, but they represent serious complications in terms of morbidity and mortality. Different therapeutic options exist, but the role of the surgeon's experience has never been investigated. The aim of this retrospective study is to assess the infection eradication success rate depending on the involvement of a septic surgeon. Method. Patients having a prosthetic-joint infection at Lausanne University Hospital (Switzerland) between 2006 and 2018 were included. The success rate depending on type of surgeon (septic vs non-septic) and type of surgical procedure was analyzed. Results. 444 patients (61% hips, 37% knees) were identified with a median age of 70 years. The overall success rate was 83% for septic surgeons compared to 61% for non-septic surgeons (p < 0.05). The effect of the surgeon was predominant in debridement with retention of the prosthesis where the experience could improve the success rate from 43% (non-septic) to 75% (septic) (p < 0.05). Conclusions. The involvement of a septic surgeon is associated with a significantly higher success rate, suggesting
Introduction. Total hip arthroplasty (THA) is a commonly performed procedure to relieve arthritis or traumatic injury. However, implant failure can occur from implant loosening or crevice corrosion as a result of inadequate seating of the femoral head onto the stem during implantation. There is no consensus—either by manufacturers or by the surgical community—on what head/stem assembly procedure should be used to maximize modular junction stability. Furthermore, the role of “off-axis” loads—loads not aligned with the stem taper axis—during assembly may significantly affect modular junction stability, but has not been sufficiently evaluated. Objective. The objective of this study was to measure the three-dimensional (3D) head/stem assembly loads considering material choice—metal or ceramic—and the surgeon experience level. Methods. A total of 29 surgeons of varying levels (Attending, Fellow, Resident) were recruited and asked to perform a benchtop, head/stem assembly using an instrumented apparatus simulating a procedure in the operating room (Figure 1). The apparatus comprised of a 12/14 stem taper attached to a 3D load sensor (9347C, Kistler® USA, Amherst, NY). Surgeons were randomly assigned a metal or ceramic femoral head and instructed to assemble the taper using their preferred surgical technique. This procedure was repeated five times. Surgeons were brought back to test the opposite material after four weeks. Output 3D load data was analyzed for differences in peak vertical load applied, angle of deviation from the stem axis—termed off-axis angle, variability between trials, and impaction location. Results. Preliminary results suggest no significant differences between the loads applied to the metal heads and the ceramic heads. Across the two materials tested, both attendings and residents applied greater loads than fellows (p=0.33; Residents=9.0 kN vs Fellow=7.2 kN: p=0.27; Attendings=8.9 kN vs 7.2 kN) with significantly less variability (Attendings: σ= 1.58; Fellows: σ= 3.26; Residents: σ= 2.86). Attending surgeons also exhibited applied loads at significantly lower off-axis angles compared to fellows (p=0.01; 4.6° vs Fellow=7.2°) (Figure 2). However, all of our clinicians assembled ceramic head tapers with a greater off-axis angle as compared to assembling metal heads. In addition, metal heads were impacted more on-axis for all surgeon experience levels (Figure 3). While the impaction load plots suggest that the first impact strike is the most crucial for head stability, it was determined that the number of strikes is not as important as the maximum impaction load applied. Conclusion. Differences in impaction load when assembling metal and ceramic femoral heads were not apparent; however, variability of technique and load was observed across the different
Introduction. Total hip arthroplasty (THA) is a physically demanding procedure where the surgeon is subject to fatigue with increased energy expenditure comparable to exercise[1]. Robotic technologies have been introduced into operating rooms to assist surgeons with ergonomically challenging tasks and to reduce overall physical stress and fatigue[2]. Greater exposure to robotic assisted training may create efficiencies that may reduce energy expenditure[3]. The purpose of this study was to assess surgeon energy expenditure during THA and perceived mental and physical demand. Methods. 12 THAs (6 cadavers) randomized by BMI were performed by two surgeons with different robotic assisted experience. Surgeon 1 (S1) had performed over 20 robotic assisted THAs on live patients and Surgeon 2 (S2) had training on 1 cadaver with no patient experience. For each cadaver, laterality was randomized and manual total hip arthroplasty (MTHA) was performed first on one hip and robotic assisted total hip arthroplasty (RATHA) on the contralateral hip. A biometric shirt collected surgeon data on caloric energy expenditure (CEE) throughout acetabular reaming (AR) and acetabular implantation (AI) for each THA procedure. Surgeon mental and physical demand was assessed after each surgery. Scores were reported from 1–10, with 10 indicating high demand. A paired sample t-test was performed between MTHA and RATHA within each surgeon group with a confidence interval of (α =0.05). Results. Each surgeon demonstrated greater CEE during MTHA, Figure 1. Surgeon CEE during MTHA was greater for S1(100±28.1 cals) compared to RATHA(83.5±0.34 cals), with no significant difference (p>0.05, p=0.49). Energy expenditure was greater for S2 during MTHA(83.5±16.3 cals) compared to RATHA(75.3±0.71 cals) with no significance (p>0.05, p=0.68). RATHA resulted in a decrease in average CEE for each surgeon with a reduction of 16.5% for S1 and 9.8 % for S2. Surgeon task time during MTHA was greater for S1(14.7±3.2 mins) compared to RATHA(12.3±4.93 mins), with no significance (p>0.05, p=0.46). Average task time was greater for S2 during MTHA(10.0±2.65 mins) compared to RATHA(8.7±2.89 mins) with no significant differences (p>0.05, p=0.66). Average mental and physical demand was less for RATHA compared to MTHA, Figure 2. Average physical demand reported during AR for MTHA(5.5±1.2) was greater than RATHA(4.3±2.0, p=0.08). Average physical demand was greater for AI for MTHA(6±1.3) than RATHA(3.7±2.1, p=0.29). Average mental demand was significantly greater during AR for MTHA(5.7±1.03) when compared to RATHA(3.2±1.5, p=0.007). Average mental demand was greater during AI for MTHA(6.2±1.2) than RATHA(2.3±1.5, p=0.051). Conclusion. Regardless of prior
Fifteen-year survivorships studies demonstrate that total knee replacements have excellent survivorship, with reports of 85 to 97%. However, excellent survivorship does not equate to excellent patient reported outcomes. Total knee imbalance with either too tight or loose soft tissues account for up to 54% of revisions in one series. This may account for many of the 20% unsatisfactory total knee arthroplasty outcomes. Soft tissue balancing technique is more like an art. The surgeon relies on subjective feel for appropriate ligamentous tension.
Background and aim. Since the market withdrawal of the ASR hip resurfacing in August 2010 because of a higher than expected revision rate as reported in the Australian Joint Replacement Registry (AOAJRR), metal-on-metal hip resurfacing arthroplasty (MoMHRA) has become a controversial procedure for hip replacement. Failures related to destructive adverse local tissue reactions to metal wear debris have further discredited MoMHRA. Longer term series from experienced resurfacing specialists however, demonstrated good outcomes with excellent 10-to-15-year survivorship in young and active men. These results have recently been confirmed for some MoMHRA designs in the AOAJRR. Besides, all hip replacement registries report significantly worse survivorship of total hip arthroplasty (THA) in patients under 50 compared to older ages. The aim of this study was to review MoMHRA survivorship from the national registries reporting on hip resurfacing and determine the risk factors for revision in the different registries. Methods. The latest annual reports from the AOAJRR, the National Joint Registry of England and Wales (NJR), the Swedish Hip Registry (SHR), the Finnish Arthroplasty Registry, the New Zealand Joint Registry and the Arthroplasty Registry of the Emilia-Romagna Region in Italy (RIPO) were reviewed for 10-year survivorship of MoMHRA in general and specific designs in particular. Other registries did not have enough hip resurfacing data or long term data yet. The survivorship data were compared to conventional THA in comparable age groups and determinants for success/failure such as gender, age, diagnosis, implant design and size and
Background. Reasons for revision of metal-on-metal hip resurfacing arthroplasty (MoMHRA) have evolved with improving
Implant selection in TKA remains highly variable. Surgeons consider pre-operative deformity, patient factors such as BMI and bone quality,
Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender.Aims
Methods
Fifteen-year survivorship studies demonstrate that total knee replacements have excellent survivorship, with reports of 85 to 97%. However, excellent survivorship does not equate to excellent patient reported outcomes. Noble et al. reported that 14% of their patients were dissatisfied with their outcome with more than half expressing problems with routine activities of daily living. There is also a difference in the patient's subjective assessment of outcome and the surgeon's objective assessment. Dickstein et al. reported that a third of total knee patients were dissatisfied, even though the surgeons felt that their results were excellent. Most of the patients who report lower outcome scores do so because their expectations are not being fulfilled by the total knee replacement surgery. Perhaps this dissatisfaction is a result of subtle soft tissue imbalance that we have difficulty in assessing intra-operatively and post-operatively. Soft tissue balancing techniques still rely on subjective feel for appropriate ligamentous tension by the surgeon.
Aims. This study was conducted to investigate the influence of
Fifteen-year survivorship studies demonstrate that total knee replacements have excellent survivorship, with reports of 85% to 97%. However, excellent survivorship does not equate to excellent patient reported outcomes. Noble et al. reported that 14% of their patients were dissatisfied with their outcome with more than half expressing problems with routine activities of daily living. There is also a difference in the patient's subjective assessment of outcome and the surgeon's objective assessment. Dickstein et al. reported that a third of total knee patients were dissatisfied, even though the surgeons felt that their results were excellent. Most of the patients who report lower outcome scores due so because their expectations are not being fulfilled by the total knee replacement surgery. Perhaps this dissatisfaction is a result of subtle soft tissue imbalance that we have difficulty in assessing intra-operatively and post-operatively. Soft tissue balancing techniques still rely on subjective feel for appropriate ligamentous tension by the surgeon.
Implant selection in TKA remains highly variable. Surgeons consider preoperative deformity,
Fifteen-year survivorship studies demonstrate that total knee replacement have excellent survivorship, with reports of 85 to 97%. However, excellent survivorship does not equate to excellent patient reported outcomes. Noble et al. reported that 14% of their patients were dissatisfied with their outcome with more than half expressing problems with routine activities of daily living. There is also a difference in the patient's subjective assessment of outcome and the surgeon's objective assessment. Dickstein et al. reported that a third of total knee patients were dissatisfied, even though the surgeons felt that their results were excellent. Most of the patients who report lower outcome scores due so because their expectations are not being fulfilled by the total knee replacement surgery. Perhaps this dissatisfaction is a result of subtle soft tissue imbalance that we have difficulty in assessing intraoperatively and postoperatively. Soft tissue balancing techniques still rely on subjective feel for appropriate ligamentous tension by the surgeon.
Introduction & aims. Satisfaction following total knee replacement (TKR) surgery remains suboptimal at around 80%. Prediction of factors influencing satisfaction may help manage expectations and thus improve satisfaction. We investigated preoperative variables that estimate the probability of achieving a successful surgical outcome following TKR in several outcomes important to patients. Method. 9 pre-operative variables (easily obtained on initial consultation) of 591 unilateral TKRs were selected for univariant then multivariant analyses. These variables included Oxford Knee Score (OKS), age, sex, BMI, ASA score, pain score, mobility aids, SF12 PCS & SF12 MCS. Using the relative predictive strengths of these variables we modeled the probabilities a successful result would be achieved for 6 patient reported outcomes at 3 and 12 months following surgery. These were ‘Excellent/good OKS’, ‘Mild/no pain’, ‘Walking without/at first a limp’, ‘No/little interference with normal work’, ‘Kneeling with little/no difficulty’ and ‘Satisfaction with surgery’. Results. Pre-operative OKS was the most useful single predictor, having impact at three months and/or one year on all outcomes examined, except kneeling. SF12 MCS affected pain scores, pain with usual activity, and limp at three months and/or one year. At three months, BMI, age, gender, ASA and pain also influenced one or more of 6 post-operative outcomes studied. After inputting pre-operative OKS, adding other predictors did not significantly improve the statistical model. Conclusions. Our model provides objective probability estimates based on the outcomes of our previous TKRs, which we can use to give specific objective information to prospective TKR patients regarding their likely postoperative trajectory. We hope this will modulate patient expectations, assist preparation for their
Fifteen-year survivorship studies demonstrate that total knee replacements have excellent survivorship, with reports of 85 to 97%. However, excellent survivorship does not equate to excellent patient reported outcomes. Noble et al reported that 14% of their patients were dissatisfied with their outcome with more than half expressing problems with routine activities of daily living. There is also a difference in the patient's subjective assessment of outcome and the surgeon's objective assessment. Dickstein et al reported that a third of total knee patients were dissatisfied, even though the surgeons felt that their results were excellent. Most of the patients who report lower outcome scores due so because their expectations are not being fulfilled by the total knee replacement surgery. Perhaps this dissatisfaction is a result of subtle soft tissue imbalance that we have difficulty in assessing intraoperatively and postoperatively. Soft tissue balancing techniques still rely on subjective feel for appropriate ligamentous tension by the surgeon.