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Daines B.K.,Orthopaedic Institute | Dennis D.A.,Colorado Joint Replacement | Amann S.,UNITED ORTHOPEDIC GROUP
Journal of the American Academy of Orthopaedic Surgeons | Year: 2015

Periprosthetic joint infections are devastating complications that are difficult and expensive to treat and have a substantial mortality rate. A major goal of modern joint arthroplasty is to minimize these infections. Preoperative factors associated with increased risk of infection include malnutrition, diabetes mellitus, obesity (body mass index >40 kg/m 2), and rheumatoid arthritis. Administration of appropriate antibiotics before the surgical incision is made is essential to minimize infection. The use of laminar flow rooms, proper skin preparation, limiting operating room traffic, and the use of various wound closure techniques can help to decrease infection rates. Postoperatively, optimal management of indwelling urinary catheters, blood transfusions, and wound drainage also may decrease infection rates. © 2015 by the American Academy of Orthopaedic Surgeons.


Unruh K.P.,Vanderbilt University | Kuhn J.E.,Vanderbilt University | Sanders R.,Vanderbilt University | An Q.,Vanderbilt University | And 16 more authors.
Journal of Shoulder and Elbow Surgery | Year: 2014

Hypothesis: The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. Methods: We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms. Results: A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures. Conclusions: There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease. Level of evidence: Level III, Cross-Sectional Study, Epidemiology Study. © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.


News Article | April 28, 2016
Site: www.technologyreview.com

Customized, printed orthopedic implants could be the future. In the meantime, the new manufacturing method is helping companies cut costs. Orthopedic surgeons are relying more and more on 3-D printing to build replacements for their patients’ defective or worn out bones. This year surgeons around the world will implant tens of thousands of 3-D printed replacements parts for hips, knees, ankles, parts of the spine, and even sections of the skull. Most of them look a lot like their conventionally made titanium counterparts. But the first few 3-D printed implants tailored specifically to an individual’s anatomy may hint at a future in which customized bone replacements are commonplace. Printed parts represent only a small fraction of the overall market for orthopedic implants, but for two important reasons that share could grow quickly in the coming years. First, an aging population is getting more joint replacement operations. The number of annual hip replacements in the U.S. doubled between 2000 and 2010. Second, in recent years engineers have gotten much better at using additive manufacturing technology—as 3-D printing is also called—to make titanium implants. Leading orthopedic implant makers are investing substantially in the development of the technology; earlier this year Stryker announced plans to build a $400 million additive manufacturing facility. Companies hope to cut costs by simplifying the production process for these implants, which are often geometrically complicated assemblies of multiple metal pieces. Building them layer by layer allows companies to consolidate many pieces into one, and save material that would be wasted in traditional subtractive manufacturing processes like forging and casting (see “10 Breakthrough Technologies 2013: Additive Manufacturing”). But perhaps the biggest potential benefit is the ability to design implants that are specific to an individual patient’s body, by using data from magnetic resonance imaging or computerized tomography scans. That’s especially true for parts of the skeleton that have complicated geometries that can be very unique to an individual, like the pelvis, says Jason Koh, an orthopedic surgeon at NorthShore University Health System and director of the NorthShore Orthopaedic Institute. Koh says customized total joint replacements could also have substantial benefits for patients. In the U.S., a few printed, custom implants have already received clearance from the Food and Drug Administration, including a total knee replacement and a craniofacial plate. It’s still very early days for custom implants. Less than 1 percent of the implants made on the electron beam melting machines sold by market-leader Arcam are patient-specific, says the company’s CEO Magnus René. René estimates that at least half of today’s additively manufactured orthopedic implants are made using Arcam’s machines. But more custom implants are under development. One hurdle might be uncertainty over how the FDA will ultimately choose to approach this new class of implants, according to Greg Kowalczyk, president of a startup called Additive Orthopaedics, which is developing a custom product. So far the agency has cleared new printed implants that it determined pose no more risk than a product already on the market, but those devices have mostly been made out of materials and based on designs familiar to the FDA. The medical value of custom implants could be “tremendous,” says Koh. But he says the technology will likely face design hurdles as well, especially in cases where the implants need to bear substantial bodyweight, such as in a hip replacement. A challenge will be identifying the specific areas in which additive manufacturing is uniquely valuable to the overall health-care system, says Koh.


News Article | April 27, 2016
Site: www.technologyreview.com

Customized, printed orthopedic implants could be the future. In the meantime, the new manufacturing method is helping companies cut costs. Orthopedic surgeons are relying more and more on 3-D printing to build replacements for their patients’ defective or worn out bones. This year surgeons around the world will implant tens of thousands of 3-D printed replacements parts for hips, knees, ankles, parts of the spine, and even sections of the skull. Most of them look a lot like their conventionally made titanium counterparts. But the first few 3-D printed implants tailored specifically to an individual’s anatomy may hint at a future in which customized bone replacements are commonplace. Printed parts represent only a small fraction of the overall market for orthopedic implants, but for two important reasons that share could grow quickly in the coming years. First, an aging population is getting more joint replacement operations. The number of annual hip replacements in the U.S. doubled between 2000 and 2010. Second, in recent years engineers have gotten much better at using additive manufacturing technology—as 3-D printing is also called—to make titanium implants. Leading orthopedic implant makers are investing substantially in the development of the technology; earlier this year Stryker announced plans to build a $400 million additive manufacturing facility. Companies hope to cut costs by simplifying the production process for these implants, which are often geometrically complicated assemblies of multiple metal pieces. Building them layer by layer allows companies to consolidate many pieces into one, and save material that would be wasted in traditional subtractive manufacturing processes like forging and casting (see “10 Breakthrough Technologies 2013: Additive Manufacturing”). But perhaps the biggest potential benefit is the ability to design implants that are specific to an individual patient’s body, by using data from magnetic resonance imaging or computerized tomography scans. That’s especially true for parts of the skeleton that have complicated geometries that can be very unique to an individual, like the pelvis, says Jason Koh, an orthopedic surgeon at NorthShore University Health System and director of the NorthShore Orthopaedic Institute. Koh says customized total joint replacements could also have substantial benefits for patients. In the U.S., a few printed, custom implants have already received clearance from the Food and Drug Administration, including a total knee replacement and a craniofacial plate. It’s still very early days for custom implants. Less than 1 percent of the implants made on the electron beam melting machines sold by market-leader Arcam are patient-specific, says the company’s CEO Magnus René. René estimates that at least half of today’s additively manufactured orthopedic implants are made using Arcam’s machines. But more custom implants are under development. One hurdle might be uncertainty over how the FDA will ultimately choose to approach this new class of implants, according to Greg Kowalczyk, president of a startup called Additive Orthopaedics, which is developing a custom product. So far the agency has cleared new printed implants that it determined pose no more risk than a product already on the market, but those devices have mostly been made out of materials and based on designs familiar to the FDA. The medical value of custom implants could be “tremendous,” says Koh. But he says the technology will likely face design hurdles as well, especially in cases where the implants need to bear substantial bodyweight, such as in a hip replacement. A challenge will be identifying the specific areas in which additive manufacturing is uniquely valuable to the overall health-care system, says Koh.


Khazzam M.,Southwestern Medical Center at Dallas | Kuhn J.E.,Vanderbilt University | Mulligan E.,Southwestern Medical Center at Dallas | Abboud J.A.,Thomas Jefferson University | And 6 more authors.
American Journal of Sports Medicine | Year: 2012

Background: Magnetic resonance imaging (MRI) is the most commonly used imaging modality to assess the rotator cuff. Currently, there are a limited number of studies assessing the interobserver and intraobserver reliability of MRI after rotator cuff repair. Hypothesis: Fellowship-trained orthopaedic shoulder surgeons will have good inter- and intraobserver agreement with regard to features of the repaired rotator cuff (repair integrity, fat content, muscle volume, number of tendons involved, tear size, and retract) on MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Seven fellowship-trained orthopaedic shoulder surgeons reviewed 31 MRI scans from 31 shoulders from patients who had previous rotator cuff repair. The scans were evaluated for the following characteristics: rotator cuff repair status (fullthickness retear vs intact repair), tear location, tendon thickness, fatty infiltration, atrophy, number of tendons involved in retear, tendon retraction, status of the long head of the biceps tendon, and bone marrow edema in the humeral head. Surgeons were asked to review images at 2 separate time points approximately 9 months apart and complete an evaluation form for each scan at each time point. Multirater kappa (k) statistics were used to assess inter- and intraobserver reliability. Results: The interobserver agreement was highest (80%, k = 0.60) for identifying full-thickness retears, tendon retear retraction (64%, k = 0.45), and cysts in the greater tuberosity (72%, k = 0.43). All other variables were found to have fair to poor agreement. The worst interobserver agreement was associated with identifying rotator cuff footprint coverage (47%, k = 0.21) and tendon signal intensity (29%, k = 0.01). The mean intraobserver reproducibility was also highest (77%-90%, k = 0.71) for full-thickness retears, quality of the supraspinatus (47%-83%, k = 0.52), tears of the long head of the biceps tendon (58%-94%, k = 0.49), presence of bone marrow edema in the humeral head (63%-87%, k = 0.48), cysts in the greater tuberosity (70%-83%, k = 0.47), signal in the long head of the biceps tendon (60%-80%, k = 0.43), and quality of the infraspinatus (37-90%, k = 0.43). The worst intraobserver reproducibility was found in identification of the location of bone marrow edema (22%-83%, k = 0.03). Conclusion: The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. Intact rotator cuff repairs or full-thickness retears can be identified with moderate reliability. These findings indicate that additional imaging modalities may be needed for accurate assessment of the repaired rotator cuff. © 2012 The Author(s).


Matava M.J.,University of Washington | Arciero R.A.,University of Connecticut Health Center | Baumgarten K.M.,Orthopaedic Institute | Carey J.L.,Vanderbilt University | And 8 more authors.
American Journal of Sports Medicine | Year: 2015

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction. © 2014 The Author(s).


Riskind P.,Press Ganey Associates | Fossey L.,Azalea Orthopedics | Brill K.,Orthopaedic Institute
Journal of Medical Practice Management | Year: 2011

Apractice that consistently and continuously measures patient perceptions will be more efficient and effective in its daily operations. With pay-for-performance requirements on the horizon and consumer rating sites already publicizing impressions from physician encounters, a practice needs to know how it is performing through the eyes of the patients. Azalea Ortho pedics has used patient feedback to coach its physicians on better patient communication. The Orthopaedic Institute has used patient satisfaction results to reduce wait times and measure the return on investment from its marketing efforts. Patient survey results that are put to work can enhance the efficiency and effectiveness of practice operations as well as position the practice for increased profitability. Copyright © 2011 by Greenbranch Publishing LLC.


Yan D.,Baoan Peoples Hospital | Wang Z.,Fifth Hospital of Zunyi | Deng S.,Baoan Peoples Hospital | Li J.,Guangzhou Medical College | Soo C.,Orthopaedic Institute
Archives of Orthopaedic and Trauma Surgery | Year: 2011

Objective This retrospective study was to evaluate the relationship between osteoporosis and dynamic cervical plates in screw-plate or screw-bone interface of elderly cervical spondylotic myelopathy (CSM) patients. Methods Retrospective study was conducted on elderly CSM patients, treated by anterior corpectomy and reconstruction with titanium mesh cages (TMC) and dynamic cervical plate between July 2004 and June 2007. All patients underwent bone mineral density (BMD) assessment in preoperation, and according to the osteoporosis degree they have been divided into two groups: moderate osteoporosis degree group and severe osteoporosis degree group. The clinical outcome [Japanese Orthopaedic Association score (JOA) and Visual Analogue Scale (VAS)], bone fusion assessment (CT mielogram), the change of titanium mesh cages and plate of cephalic screw-plate-angle (SPA) and cephalic endplate-plate-angle (EPA) of plain X-ray Wlms were measured. Results The mean JOA score and recovery rate were not different between the two groups (P > 0.05). There was no loss of sagittal alignment after surgery in any patient, and no significant difference between both groups on lordosis measurements (P > 0.05). Although there was a significant difference of the cage subsidence rate between the two groups (P < 0.001), all patients had favorable bone union and none required additional treatment. The average changes of SPA were greater in A group patients than in B group patients, while the variation of EPA was higher in B group patients than in A group patients (P < 0.001). Conclusions Despite the fact that there is a significant difference of the cage subsidence rate between the two groups no clinical outcome, nor sagittal alignment or fusion rate differences among groups was observed in elderly CSM patients. © Springer-Verlag 2011.


Puhaindran M.E.,Level 11 | Rothrock C.P.,Orthopaedic Institute | Athanasian E.A.,Sloan Kettering Cancer Center
Hand | Year: 2011

Background: Malignant tumors of the thumb can be treated surgically with either wide local excision with reconstruction or amputation. Local excision of tumors in the thumb and hand often requires closer resection margin than at other sites, and there is also a need for tissue transfer from a donor site for reconstruction. Primary thumb amputation allows local tumor control while avoiding donor-site morbidity, but comes at great functional cost. We conducted this retrospective case review to assess the outcomes of thumb-sparing wide excisions and primary thumb amputations for malignant thumb tumors. Methods: We performed a retrospective review of 23 patients who were surgically treated for malignant tumors of the thumb at our center from 1996 to 2005. We reviewed patient demographics, tumor pathology, extent of resection, postoperative margin status, adjuvant therapy, recurrence, and survival. Functional outcomes were scored using the Muscular Skeletal Tumor Society (MSTS) rating system. Results: Twenty-three patients underwent definitive surgery: 14 thumb-sparing wide excisions and 9 amputations (five at the interphalangeal joint, three at the metacarpophalangeal joint, and one at the forearm). Median follow-up was 58 months (range, 5-156 months). All patients had negative margins. One patient developed a local tumor recurrence (following below-elbow amputation for a soft tissue sarcoma) while three patients developed distant metastases and died from their disease (two patients had melanomas and one had a soft tissue sarcoma). The median MSTS functional score was 28 (IQR, 27-29) for the entire cohort. Two patients that underwent amputation at the metcarpophalangeal joint without reconstruction had the lowest scores of 11 and 17. Conclusion: There was a low incidence of local recurrence and distant metastasis in this study, and these events appeared to be related to the underlying disease rather than the surgery performed. Thumb-sparing wide excision and amputation at the interphalangeal joint both give acceptable functional outcomes, though reconstruction should be strongly considered for patients undergoing amputation at the metacarpophalangeal joint. © 2011 American Association for Hand Surgery.


PubMed | Orthopaedic Institute and Georgia Institute for Plastic Surgery
Type: Journal Article | Journal: Hand (New York, N.Y.) | Year: 2014

The purpose of this study was to report on the injury patterns and outcomes of a series of patients treated at our institution between the years 1983 and 2010 who were injured by rings worn on their finger. The series included typical ring avulsion injuries as well as all other injuries caused by rings.Retrospective chart review was conducted on 33 patients with ring injuries treated by the senior author and colleagues. Eight cases were classified as Urbaniak class I, 13 class II, and 12 class III.Satisfactory finger motion occurred with salvage of fingers in which no damage occurred to the proximal phalanx or flexor digitorum sublimus or profundus tendons. All patients with flexor tendon injury or proximal phalangeal fracture or both had loss of PIPJ motion and total active motion as compared to class II injuries without tendon and bone involvement. Four class III injuries were treated with replantation. One failed requiring revision amputation at the metacarpalphalangeal joint level due to ischemia. The remaining eight were treated by primary amputation.As a guideline to digit salvage with ring injuries, the authors propose accurately documenting and basing treatment on all injured structures. Particular attention should be given to fractures of the proximal phalanx and laceration of the flexor digitorum sublimus and profundus tendons, as injury to these structures led to significant loss in mobility of the finger in this series. While some current guidelines advise revascularization of class II ring avulsion injuries, our series suggests caution in anticipating good results with sublimus or profundus tendon laceration and proximal phalanx fracture. If the profundus tendon only is lacerated, particularly in zone I injuries, results of finger salvage may still be acceptable, but associated (distal interphalangeal joint) DIPJ injury may require K-wire stabilization and later fusion. Replantation in class III injuries, while possible, is warranted only in select situations (patient-specific and cultural factors).

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