Abstract:

This study was performed to determine whether differences existed between primary knee replacement performed through a standard medial parapatellar approach, and those performed through a minimally invasive mini-mid vastus approach. It was a prospective study compared with a retrospective evaluation of a matched cohort. In this study, the Genesis™ II and its MIS instrumentation were used. Patients with the mini-mid vastus MIS incision (MMV MIS) required less pain medication post-operatively, regained their flexion more rapidly, and attained their functional milestones at an earlier point than those with the traditional median parapatellar long incision. Despite the smaller incision, component placement was radiographically excellent in all cases. Optimal performance of the surgery required the use of special instrumentation, modified so as to be used in smaller incisions.

Authors:

Richard S. Laskin, M.D.

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Abstract:

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most successful procedures performed in terms of quality-of-life years gained. The long-term goals of arthroplasty, to relieve pain, increase function, provide stability, and obtain durability, are accomplished in the vast majority of cases. The short-term goals, however, have become the target of aggressive peri-operative programs that aim to speed recovery, reduce morbidity and complications, and create a program of efficiency while maintaining the highest level of patient care. The concept of rapid recovery is built upon the burgeoning interest in less-invasive and small-incision surgeries for (THA and TKA). However, the incision size does not appear to be the most critical aspect of the program. This article outlines the specific elements of the rapid-recovery program for lower-extremity arthroplasty patients, including pre-operative patient education, peri-opera-tive nutrition, vitamin and herbal medication supplementation, preemptive analgesia, and post-operative rehabilitation. A holistic peri-operative, rapid-recovery program has lead to a significantly decreased hospital length of stay and significantly lower hospital readmission rates in patients who undergo primary THAs and TKAs. Combining these results with minimally invasive techniques and instrumentation should make recovery even faster.

Authors:

Keith R. Berend, M.D., Adolph V. Lombardi, Jr., M.D., F.A.C.S., Thomas H. Mallory, M.D., F.A.C.S.

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Abstract:

Between 5% to 10% of tibial fractures progress to nonunion, causing substantial disability. Bone autografts, along with internal fixation, are the usual treatment for these failures, but the morbidity associated with autogenous tissues remains problematic. Bone morphogenetic proteins are currently available for clinical use and preclinical models, as well as an increasing number of patients treated with these molecules demonstrate their safety and efficacy. Osteogenic Protein-1, OP-1, has been evaluated in a randomized, prospective, multi-institution study of tibial nonunions. Sixty-one patients with 63 nonunions received OP-1 and intramedullary rod fixation, and were compared with 61 patients with 61 nonunions treated with fresh autogenous bone graft and the same fixation. Clinical outcomes (success in 81% of OP-1 and 85% of autograft-treated patients) and radiographic evaluation (healing in 75% of OP-1 and 84% of autografttreated patients) were statistically indistinguishable at 9 months following treatment. No OP-1 or graft-related adverse events occurred. More than 20% of the autograft group had significant donor-site pain 6 months following surgery. OP-1 is a safe and effective alternative to autogenous bone in treatment of tibial nonunions.

Authors:

Gary E. Friedlaender, M.D.

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Abstract:

Survivorship analysis has demonstrated the excellent long-term clinical success of total knee arthroplasty (TKA). Despite multiple attempts to enhance fixation with cementless technology, cemented TKA continues to be the "gold standard." The rate of loosening has diminished as the accuracy of implantation has been improved through sophisticated instrumentation and enhanced experience. Current technology with respect to computer-assisted surgery serves only to improve the accuracy of implantation, leaving materials as the weakest link in the long-term survivorship of TKA. Failure secondary to polyethylene wear has ranked as one of the most frequent causes for revision. Many issues have been identified as contributory to polyethylene wear and include the quality of the polyethylene, manufacturing process, nature of the tibial-femoral or patellofemoral articulation, area of contact, sterilization process, and issues pertaining to modularity and so-called backside wear. Long-term clinical studies have documented the success of direct compression-molded monoblock tibial components. However, the benefits of modularity are widely recognized and include the ability to fine tune soft-tissue balance after implantation of metallic devices. In an effort to combine the long-term success of direct compression molded monoblock tibial components with the occasional need for modularity, a convertible tibial component has been introduced. This device is manufactured as a direct compression-molded monoblock tibial component. The surgeon has the ability at the time of the surgical intervention, or any subsequent intervention, to convert the tibial component into a modular device. Therefore, this device addresses, in the majority of cases, the concerns that arise from backside wear.

Authors:

Adolph V. Lombardi, Jr., M.D., F.A.C.S., Keith R. Berend, M.D., Thomas H. Mallory, M.D., F.A.C.S.

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Abstract:

Fondaparinux (Arixtra®, GlaxoSmithKline, Philadelphia, PA.) is the first synthetic selective factor Xa inhibitor. A worldwide phase III program, that consists of four randomized, double-blind trials, in patients who underwent surgery for hip fracture, and elective hip replacement and elective major knee surgery was conducted to compare the benefit-to-risk ratio of a subcutaneous 2.5 mg once-daily regimen of fondaparinux starting postoperatively versus enoxaparin in preventing venous thromboembolism. The overall incidence of venous thromboembolism up to day 11 was reduced from 13.7% in the enoxaparin group, to 6.8% in the fondaparinux group, with a relative risk reduction of 50.6% in favor of fondaparinux (95% confidence interval: 40.9% to 59.1%, p<0.001). The overall incidence of clinically relevant bleeding was low and did not differ between the two groups. The benefit of fondaparinux was consistent across all types of surgery and all subgroups. The further randomized, double-blind PENTHIFRA-PLUS trial showed that extending fondaparinux prophylaxis from one to four weeks after hip fracture surgery was well tolerated and, compared to one-week fondaparinux, dramatically reduced delayed venous thromboembolism events from 35.0% to 1.4% (p<0.001). Four-week fondaparinux could become the standard thromboprophylaxis after hip fracture surgery. Fondaparinux is the first selective factor Xa inhibitor approved for use in thromboprophylaxis after orthopedic surgery.

Authors:

A. G. G. Turpie, M.D., F.R.C.P., F.A.C.C.

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Abstract:

Permanent palsies of the median nerve cause severe impairment of hand functions. This chapter reviews both the various surgical methods able to restore functions and complex mechanisms necessary for brain adaptation to the new functions of the cortical areas. Different methods of reconstructive surgery, according to both the severity of palsy and patients' needs, are presented. The contemporary restoration of sensory function of the paralysed digits is recommended, as sensation is a prerequisite for good motor function. The various mechanisms and methods useful to obtain good gliding and strength of the transferred tendons are stressed. Reconstructive surgery for permanent palsy of the median nerve can supply improved function, provided that all the recommendations for a meticulous balance of the number of functions to be restored and available motors to be transferred, as well as of their strength and course, are addressed.

Authors:

Giorgio A. Brunelli, M.D., Giovanni A. Brunelli, M.D.

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Abstract:

The objective of this chapter was to demonstrate evolving transforaminal endoscopic microdecompression for herniated lumbar discs and spinal stenosis, and to become accomplished with endoscopic micro spinal instruments and laser application. Since 1993, 2000 patients with 3421 herniated lumbar discs were diagnosed with symptomatic lumbar single and multiple herniated intervertebral discs. Progressive series of different diameters endoscopic-assisted tubular retractors, with appropriate-sized dilators and more aggressive saw-toothed trephines, and laser were used to perform transforaminal endoscopic microdecompression, in addition to the posterior-lateral foraminoscope and endoscopic-assisted spinal operating systems. No postoperative mortalities occurred, and the morbidity rate was less than 1%, in the 2000 patients. For a single level, 94% of the patients had good or excellent results; 6% had some residual symptoms although improved overall. Transforaminal endoscopic laser microdecompression can effectively decompress herniated lumbar discs and spinal stenosis, when foraminoplasty is performed, which provides a safe and effective modality to achieve results in effective spinal decompression, preserves spinal motion, and creates a channel for spinal arthroplasty.

Authors:

John C. Chiu, M.D., D.Sc, F.R.C.S.

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