Abstract:

The use of large-diameter femoral heads in total hip arthroplasty appears to reduce the risk for dislocation, and potentially improve articular wear. Moreover, large-diameter total hip femoral heads have been determined to increase range of motion. The purpose of this study was to report our experiences with this new device. In our patient cohort, many patients have done extremely well in the short-term with this new device, and it seems these patients function better than those with a standard total hip arthroplasty. The patients who experience less pain are able to return to full activities postoperatively. The preliminary results of this study are encouraging, and large femoral head prosthesis appears to be a great choice for orthopaedic surgeons in primary total hip arthroplasty.

Authors:

Thorsten M. Seyler, M.D., Rubin Institute for Advanced Orthopedics; Gracia Etienne, M.D., Ph.D., Rubin Institute for Advanced Orthopedics; Johannes F. Plate, B.S., Rubin Institute for Advanced Orthopedics; Patrick Fisher, M.B.A., Hip Division Wright Medical Technology; Michael A. Mont, M.D., Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD

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Abstract:

Inability to achieve adequate range of motion (ROM) after total knee arthroplasty (TKA) represents a frustrating complication for both patient and surgeon. Manipulation under anesthesia is indicated in TKA having less than 90° ROM after six weeks, with no progression or regression in ROM. A modified technique has evolved for patients with chronic regional pain syndrome (CRPS) symptoms or persistent stiffness after standard manipulation. A retrospective review was conducted to determine the efficacy of the modified technique, which uses epidural anesthesia continued for postoperative analgesia, hospital stay of one to three days, continuous passive motion (CPM) for two to three days, and daily physical therapy (PT). Between 1997 and 2003, 5714 TKAs were performed in 4106 patients. Manipulation using a standard technique was performed on 334 (5.8%) knees in 273 patients. Manipulation using a modified technique was performed on 65 (1%) knees in 60 patients. Age averaged 58 years and body mass index (BMI) averaged 34.39. Follow up averaged 18.4 months. ROM improved significantly from 71° to 102° (p<0.0001). Knee Society pain, function, and total clinical scores all improved significantly (all p<0.0001). Successful results were observed in 48 (74%) knees. Four (6%) additional knees achieved a successful result after a subsequent manipulation. Nine (14%) knees required component revision for treatment of persistent arthrofibrosis, which included one full revision, five polyethylene exchanges, and three revisions of femoral component and polyethylene. Two significant complications occurred: one subdural hematoma and one death due to pulmonary embolism. Although not without complications, manipulation under epidural anesthesia represents a viable option for treatment of persistent stiffness after TKA; 80% of these difficult cases achieved successful results.

Authors:

Gerardo Mangino Pariente, M.D., Joint Implant Surgeons, Inc., Hospital ABC Sante Fe, Mexico, Joint Implant Surgeons, Inc., The Ohio State University, New Albany Surgical Hospital, New Albany, OH, Hospital ABC Santa Fe, Mexico; Adolph V. Lombardi, Jr., M.D., F.A.C.S., Joint Implant Surgeons, Inc., Orthopaedic Surgery, The Ohio State University, Biomedical Engineering, The Ohio State University, New Albany Surgical Hospital, OH; Keith R. Berend, M.D., Joint Implant Surgeons, Inc., The Ohio State University, Joint Implant Surgeons, Inc., The Ohio State University, New Albany Surgical Hospital, New Albany, OH; Thomas H. Mallory, M.D., F.A.C.S., Joint Implant Surgeons, Inc., The Ohio State University, Joint Implant Surgeons, Inc., The Ohio State University, New Albany Surgical Hospital, New Albany, OH; Joanne B. Adams, B.F.A., Joint Implant Surgeons, Inc., The Ohio State University, New Albany Surgical Hospital, New Albany, OH

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Abstract:

Background: Optimized pulsed electrical stimulation (PES) regulates chondrocyte genes, enhances production of cartilage matrix materials, and inhibits production of matrix catabolic factors. Methods: This prospective, cohort study examined the use of a PES device in treatment of knee osteoarthritis (OA) in patients who had failed non-operative therapy. Primary outcome measures were patient and physician global evaluation, and patient assessment of knee pain.

Authors:

Jack Farr, M.D., Indiana University Medical Center, Indianapolis, IN; Michael A. Mont, M.D., Rubin Institute for Advanced Orthopedics, Baltimore, MD; Douglas Garland, M.D., University of Southern California, Long Beach, CA; Jacques R. Caldwell, M.D., Bionicare Medical Technologies, Inc., Sparks, MD; Thomas M. Zizic, M.D., Johns Hopkins University School of Medicine, Baltimore, MD, Bionicare Medical Technologies, Inc., Sparks, MD

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Abstract:

In response to the rapid development and demand of outpatient endoscopic minimally invasive lumbar surgical technique, the SMART® endoscopic spine system was developed for neurodecompression. This lumbar spine surgery is performed with a small skin incision, dilatation surgical technology, and an endoscopic-assisted spinal surgical system with progressive serial tubular retractors providing superior lighting and better visualization of the operative field for performing minimally invasive spinal surgery (MISS). The SMART® system incorporates the advantages of posterior paramedian endoscopic assisted microdecompressive surgical spinal system and posterolateral endoscopic lumbar system. This versatile SMART® endoscopic spine system with various sized working channels provides a generous and optimal access for endoscopic MISS of microdecompression of herniated lumbar discs, degenerative spinal disease, spinal stenosis, and removal of intraspinal lesions as well as creating an access for spinal arthroplasty and spinal fixation. With the unique features of the SMART® system, the surgeon can take advantage of microscopic, endoscopic, or direct vision for microdecompressive spinal surgery, bridging endoscopic and conventional spinal surgery. It appears to be easy, safe, and efficacious. This less traumatic and easier outpatient MISS treatment leads to excellent results, speedier recovery, and significant economic savings. The SMART® endoscopic spine system, surgical indications, operative techniques, and the potential complications and their avoidance are described and discussed herein.

Authors:

John C. Chiu, M.D., F.R.C.S., D.Sc., California Center for Minimally Invasive Spine Surgery, California Spine Institute Medical Center, Newbury Park, CA

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Abstract:

The degenerative processes in an aging spine have been defined traditionally only by our knowledge of the biology of disc and facet degeneration, as well as interpretation of post-mortem cryosections by forensic anatomist Wolfgang Rauschning, M.D. In this chapter, visualization of in-vivo patho-anatomy in a degenerating disc and spinal segment is demonstrated at surgery using the Yeung Endoscopic Spine System™ (Y.E.S.S.™), (Richard Wolf Surgical Instrument Company, Vernon Hills, IL, USA). An Institutional Review Board (IRB)-approved study of endoscopic treatment for degenerative conditions of the lumbar spine incorporated intraoperative probing under local anesthesia and endoscopic treatment of the visualized patho-anatomy. An intraoperative evocative chromo-discogram, using indigocarmine, was used to elicit discogenic pain and label the fissured and degenerative nucleus pulposus for surgical removal and thermal modulation. Painful patho-anatomy was probed in a conscious patient. The most common endoscopic finding was Inflammatory tissue in the disc and annulus. Inflammation was correlated with the presence of annular tears. Patho-physiologic changes that affect the exiting nerve, which contains the Dorsal Root Ganglion (DRG), was associated with stenotic and chemical irritation. Unavoidable postoperative dysesthesia was associated with the presence of an inflammatory membrane, and removal or thermal coagulation of "anomalous" furcal nerves in the foramen that branched off of the exiting spinal nerve. Neo-angiogenesis and neurogenesis in the inflammatory membrane present in the foraminal triangle was a new finding not reported in traditional clinical studies. Visualization and treatment of pathologic findings inside (annular tears) and outside the disc in Herniated Nucleus Pulposus (HNP), synovial cysts, foraminal stenosis, central stenosis, spondylolisthesis, is demonstrated. The endoscopic foraminal approach to the spine and disc is a technique that provides access to patho-anatomy in the lumbar spine not usually feasible with traditional surgical methods. Favorable surgical results allow for continued evolution of the endoscopic method, concomitant with the continued evolution of endoscopic spinal surgery.

Authors:

Anthony T. Yeung, M.D., Arizona Institute for Minimally Invasive Spine Care, Phoenix, AZ, University of California San Diego School of Medicine, San Diego, CA; Christopher A. Yeung, M.D., Arizona Institute for Minimally Invasive Spine Care, Phoenix, AZ, University of California San Diego School of Medicine, San Diego, CA

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Abstract:

Spinal tumors that are radioresistant or cause bony compression of the spinal cord often require surgical decompression to protect or restore neurological function. Metastatic lesions and primary tumors such as multiple myeloma usually arise in the vertebral body, which can collapse and become unstable, and can compress the anterior columns of the cord. Laminectomy is often ineffective in these patients, and direct anterior decompression through thoracotomy is the widely-accepted solution to the neurological problem. The anterior surgical approach is particularly challenging in the upper thoracic spine. Patients with limited pulmonary reserve due to pneumonectomy or pulmonary metastasis might not tolerate the loss of lung capacity necessitated by either thoracotomy or thoracoscopy. Because posterior instrumentation is usually needed to provide stability following corpectomy and spinal cord decompression, posterolateral approaches to spinal cord decompression have gained favor in recent years. Posterolateral decompression offers advantages over the combined anterior and posterior approach, reducing operative time, morbidity, and hospital stay. Drawbacks to traditional posterolateral decompressions include poor visualization of the tumor immediately anterior to the spinal cord and the need to manipulate the spinal cord to completely remove a tumor adherent to the dura. Endoscopically assisted posterolateral decompression allows decompression of the anterior surface of the spinal cord, the point of pressure in most circumstances. Endoscopic video assistance facilitates vertebrectomy, cord decompression, and anterior reconstruction, all performed through the same posterior incision. Endoscopic assisted spinal cord decompression dramatically reduces morbidity, ICU requirements, and inpatient hospitalization and has proven useful for a variety of metastatic tumors at every level of the spinal column.

Authors:

Selvon F. St. Clair, M.D., Ph.D.; Robert F. McLain, M.D., Lerner College of Medicine, Cleveland Clinic Spine Institute, Cleveland Clinic Foundation, Cleveland, OH

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Abstract:

With increased life expectancy and an aging population, many patients suffering from progressive lumbar spinal stenosis with symptomatic neurogenic intermittent claudication (NIC) have been limited to a choice between nonsurgical therapies or a more traumatic decompressive surgical procedure, with or without lumbar fusion. The interspinous process decompression (IPD) system, the X-STOP® implant, was developed to provide a minimally invasive alternative therapeutic treatment of lumbar spinal stenosis. The X-STOP® IPD system, surgical indications, operative techniques, and the potential complications and their avoidance are described and discussed herein.

Authors:

John C. Chiu, M.D., F.R.C.S. (U.S.), D.Sc., California Center for Minimally Invasive Spine Surgery, California Spine Institute Medical Center, Newbury Park, CA

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Abstract:

Twenty-eight patients who suffered traumatic obsolete incomplete paralysis were treated with intradural lysis and peripheral nerve implantation by a microsurgery technique. The endorachis was opened and the fibrous bands adhering to the spinal cord from the arachnoid, pia mater spinalis, ligamenta denticulatum, and the initial part of the nerve root were completely relieved. The abnormal spinal cord was then opened by three to six incisions, which were each 0.1 mm to 0.2 mm deep and longer than the abnormal portion. A cyst found in the back or side of the spinal cord was opened and the liquid in it was drained. After that, the denuded spineurium and perineurium of the autogenous sural nerve were grafted, which makes the character and aspect of the nerve like the cauda equine. The nerve was longitudinally implanted into the incised spinal cord, and the cyst was waded with grafted nerve and at least one of them is ectropion sutured with the pia mater with 9-0 scatheless wire as a drain. Finally, the endorachis was covered by sacrospinal muscle flap. These patients were followed for 2 years to 8 years (average 3.5 years), and the sensibility and motion of each increased at least one grade. The strength of the main muscle was increased two grades and reached four grades in 11 patients, and the capability to walk was recovered. Relieving of the adhesion in the endorhachis, carving the cicatricial spinal cord, and implanting the autogenous peripheral nerve yields good results by initial clinical observation for traumatic obsolete and incomplete paralysis.

Authors:

Shao-Cheng Zhang, M.D., Changhai Hospital, Shanghai, China; Yuhai Ma, M.D., Changhai Hospital, Shanghai, China; Hui-ren Liu, M.D., The Second Hospital of Tangshan, Hebei Province, China; Xue-song Zhang, M.D, Changhai Hospital, Shanghai, China; Yongtai Pan, M.D., The 180th Hospital of PLA, Fujian Province, China; Xu-dong Zheng, M.D., Central Hospital, Beijing, China

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Abstract:

This article presents the results of a retrospective review of six osteochondral lesions on six patients (five men and one woman) treated with transplantation of cryopreserved talar allograft and ankle joint distraction. All patients complained of ankle pain existing for a long time secondary to a traumatic episode confirmed through MRI. Lesions ranged in measurement from 0.8 cm × 0.8 cm to 3.2 cm × 1.8 cm with an average size of 2.1 cm × 1.5 cm. Each patient underwent talar dome transplantation using fresh frozen talar allograft followed by ankle distraction. Distraction was obtained using a three-ring multiplanar external fixation device. All surgeries were performed between 2002 and 2004. All external fixators were removed at 8 weeks and patients remained partial-weight bearing in a removable cast boot for an additional 8 weeks. Serial postoperative radiographs showed complete consolidation of the allograft within 16 weeks. The average follow up time was 24 months, and all patients related a subjective decrease in symptoms and increase in activity levels. Patients were also evaluated utilizing the Maryland Foot Score both pre- and postoperatively. Preoperatively, four patients were graded as fair and two were graded as poor. Postoperatively, two patients related excellent results, three patients related good results, and one patient related fair results. Several patients experienced minor complications such as pin site irritation (five patients), painful talar wire (one patient), and periostitis (one patient). No patients experienced any major complications and none have required additional surgery. We feel that these initial results warrant further investigation of this treatment.

Authors:

Edgardo G. Rodriguez, D.P.M., Chicago Foot and Ankle Deformity Correction Center, Chicago, IL; Jeffrey P. Hall, D.P.M., St. Joseph Hospital/NCVA, PM&S-36 Podiatry Residency Program, Chicago IL; Raymond L. Smith, D.P.M., Chicago Foot and Ankle Deformity Correction Center, Chicago, IL; John P. Rachoy, D.P.M., Chicago Foot and Ankle Deformity Correction Center, Chicago, IL; Tomasz Szmyd, D.P.M., St. Joseph Hospital/NCVA, PM&S-36 Podiatry Residency Program, Chicago IL

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