Sacroiliac (SI) joint pain is often overlooked as a source of mechanical lower back pain. Some estimates suggest that it may account for nearly 25% of chronic, non-radicular pain. Given its anatomical proximity to the hip joint, a thorough physical examination may reveal overlapping provocative tests between the two articulations. The trend of sub-specialization may lead to clinically significant oversights in relation to lower back and hip pain. Arriving at a proper differential diagnosis is made more difficult during physical examination of the hip, as the full range of motion of hip extension also incorporates SI rotation and extension of the lumbar spine. This is further compounded by the anatomy of the SI joint and the absence of a true diagnostic gold standard. When several provocative tests are used together, studies have shown far greater validity, reliability, and accuracy than when used alone. The wide assortment of provocative tests to pinpoint SI joint dysfunction highlights the challenging nature of such symptomatology. The purpose of this study is to determine the incidence of positive provocative SI joint tests in patients presenting with a primary complaint of hip pain. Further investigation will determine which tests produce more positive results in patients with hip pain and if some SI joint tests are more specific to the SI joint itself.
Introduction: Robotic pancreatoduodenectomy (RPD) remains a complex and relatively uncommon procedure with significant technical heterogeneity. This study aims to analyze current practices in RPD among surgeons with extensive experience and high annual volumes. Methods: A survey was submitted to 230 RPD experts worldwide. High-level expertise was defined as having more than 5 years of RPD experience and performing over 20 RPDs per year. Results: A total of 51 responses (22%) from 16 countries were analyzed. The heterogeneity among the respondents was significant. Most surgeons preferred pancreatojejunostomy over pancreatogastrostomy. Experienced experts more often selected manual over mechanical gastrojejunostomy (p = 0.007), end-to-side gastrojejunostomy (p = 0.015), and port incision enlargement (p = 0.016) rather than a Pfannestiel incision for specimen retrieval. Conclusion: Only a limited degree of consensus exists among expert hepato-pancreato-biliary surgeons regarding RPD techniques. Therefore, consensus-based recommendations on all RPD steps are needed to help standardize the procedure.
Materials and Methods: A retrospective chart review of a single orthopedic sports medicine surgeon was performed identifying patients who underwent primary or revision ACL reconstruction (ACLR) augmented with an RBI between January 2021 and January 2024. Inclusion criteria included: age over 14, minimum one-year follow up, and range of motion, Visual Analog Scale (VAS) and International Knee Documentation Committee (IKDC) scores at preop, three months, six months, and 12 months postoperative. Excluded patients were primary ACL repair and failure to meet the above criteria. Patients were identified for medical comorbidities and outcomes related to the need for reoperation and/or identification of graft tears.
3Department of Gastroenterological Surgery, Clinique Clementville, Montpellier, France
INTRODUCTION:Technology is increasingly incorporated into unicompartmental knee arthroplasty (UKA) through computer-assisted navigation (N-UKA) and robot-assisted surgery (R-UKA) to improve alignment, implant positioning, and gap balancing. Whether intraoperative technology helps achieve the minimal clinically important difference (MCID) in patient-reported outcomes (PROMs) compared to conventional UKA (C-UKA) remains unclear. This systematic review aimed to assess whether differences in PROMs between C-UKA and technology-assisted UKA reached MCID values. MATERIALS AND METHODS:PubMed/MEDLINE/Cochrane Library were reviewed for studies comparing PROMs between primary C-UKA (control group) and N-UKA or R-UKA. Delta improvements were compared to established MCID values. Additional radiographic and clinical differences were assessed. The review yielded four (N=328) N-UKA and seven (N=526) R-UKA studies with C-UKA cohorts as controls. RESULTS:Differences in preoperative and postoperative PROMs were reported as statistically significant in three of four studies (75%) comparing N-UKA and C-UKA; however, none of the studies reported values that reached the MCID. Differences in preoperative and postoperative PROMs were reported as statistically significant in four of seven studies (57.1%) comparing R-UKA and C-UKA; however, only three of the studies (42.9%) reported values that reached the MCID. Improved radiographic outcomes for N-UKA and R-UKA were reported in 75% and 57.1% of studies, respectively. Only one study reported improved revision rates with R-UKA compared to C-UKA. CONCLUSION:Though studies may report better improvements in PROMs in N-UKA and R-UKA compared to C-UKA, these often may not achieve clinical significance. Future studies should present outcome differences in the context of validated MCID as well as other metrics such as revision rates and radiographic outliers as the impetus for technology-assisted UKA.
INTRODUCTION:Acetabular revision surgery is challenging due to the occurrence of bony defects that complicate the fixation of implants after removal of loose components. In addition to multimorbidity and increased risk of falling, poor bone quality in geriatric patients makes it even more difficult to secure implant anchoring. The aim of this study was to evaluate the clinical and radiographic results after revision arthroplasty with the MUTARS® RS cup system (implantcast GmbH, Buxtehude, Germany) in geriatric patients (age >70 years). MATERIALS AND METHODS:From 2019 to 2023, 24 geriatric patients, six males and 18 females, with a mean age of 79.2 years (range, 70-94 years) underwent a revision surgery and were provided with the MUTARS® RS cup system at the geriatric center of the Dessau Municipal Hospital. After a mean follow up of 2.5 years (range, 1-4 years), the clinical evaluation and patient-reported outcomes were measured using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Hip Score (OHS), and EQ-5D-5L. Radiographs were taken to evaluate radiolucent lines and component migration. RESULTS:A total of 19 patients (79.2%) remained without any revision until the latest follow up. The average HHS was 71.1 (range, 56-93), the average OHS was 23.7 (range, 10-40), and the average WOMAC was 20.4 (range, 1-70). According to EQ-5D-5L, there were 10 patients (52.6%) with slight problems, seven patients (36.8%) with moderate problems, and two patients (10.5%) with severe problems. The x-ray showed no migration of the components; 15 cases (78.9%) had radiolucent lines around the caudal flap in the os ischii. CONCLUSION:The RS Cup is a suitable implant for revision surgery with large bone defects or acetabular fractures. "Clinically satisfactory" to "good" results are shown, with mild and moderate problems for geriatric patients which are already predominantly constrained by pre-existing multimorbidity.
INTRODUCTION:Robotic-assisted total knee arthroplasty (TKA) allows surgeons to individualize implant placement based on soft tissue and bony anatomy, called functional knee positioning (FKP). We aimed to compare patient-reported outcome measures (PROMs) of mechanically aligned total knee arthroplasty (MA-TKA) with functionally positioned total knee arthroplasty (FP-TKA). MATERIALS AND METHODS:Patients who underwent primary MA-TKA and FP-TKA were propensity score matched 1:1 (145 MA-TKA: 145 FP-TKA cases) using a prospectively collected institutional dataset. For FP-TKA cases, the surgeon followed functional positioning principles, individualizing planned implant position to balance the knee prior to bone cuts while minimizing the need for soft tissue releases. For MA-TKA, cases were mechanically aligned and gap balanced using standard techniques. The postoperative reduced Western Ontario and McMaster Arthritis Score (r-WOMAC) Pain and Function scores were compared at six months and one year using average and t-tests. The length of stay (LOS), as well as knee extension and flexion at six weeks were compared. RESULTS:There was no statistically significant difference in the r-WOMAC pain and r-WOMAC function scores between both groups at six months; however, both trended towards the FP-TKA group. At one year, the r-WOMAC function scores significantly improved for the FP-TKA group compared to controls (2.94 vs. 4.38; p=0.02). There was no significant difference in the r-WOMAC pain scores at one year. The FP-TKA cohort required a shorter LOS compared to those who had MA-TKA (1.75 vs. 2.36; p<0.0001). There was no significant difference in flexion or extension at six weeks between groups (p=0.77 and 0.18, respectively). CONCLUSION:We demonstrate that patients who underwent FP-TKA trended toward functional improvements at six months and significant improvements in function at one year (which did not reach minimally clinical important difference). Functional positioning strategies may improve patient-reported outcomes due to minimizing dissection and personalizing implant position.
INTRODUCTION:The purpose of this study was to examine the risk of early clinical outcomes in ACL reconstructions augmented with a reinforced bio-inductive implant (RBI). MATERIALS AND METHODS:A retrospective chart review of a single orthopedic sports medicine surgeon was performed identifying patients who underwent primary or revision ACL reconstruction (ACLR) augmented with an RBI between January 2021 and January 2024. Inclusion criteria included: age over 14, minimum one-year follow up, and range of motion, Visual Analog Scale (VAS) and International Knee Documentation Committee (IKDC) scores at preop, three months, six months, and 12 months postoperative. Excluded patients were primary ACL repair and failure to meet the above criteria. Patients were identified for medical comorbidities and outcomes related to the need for reoperation and/or identification of graft tears. RESULTS:Seventy-one patients met the inclusion criteria with mean follow up of 12.2 months (min. 11, max. 23, median 12). Patient demographics revealed an average age of 29 years (min. 14, max. 62, median 28). Of the 71 patients, 37 (52.1%) were male. All 71 patients had their ACLR performed arthroscopically, and 61/71 patients underwent primary ACL reconstruction (85.9%). VAS pain scores at three, six, and 12 months compared to pre-surgical scores revealed statistically significant decreases at all timepoints (Δ-3.4, Δ-3.8, Δ-3.8, respectively, p <0.001). IKDC scores at three, six, and 12 months compared to pre-surgical scores met the minimal clinically important difference (MCID) and were found to have statistically significant improvements at all timepoints (Δ25.9, Δ42.8, Δ49.7, respectively, p <0.001). Knee ROM in flexion and extension demonstrated statistically significant improvements at all timepoints post surgery compared to baseline (p <0.001). The overall rate of reoperation was 4.2% (3/71). Reasons for reoperation included one case of arthrofibrosis (1.4%), one subsequent meniscus tear (1.4%), and one graft retear (1.4%). CONCLUSION:The addition of an RBI to ACLR demonstrated favorable outcomes in terms of range of motion, pain, and functional outcome scores with a low rate of clinical retear at a minimum of one-year follow up.
INTRODUCTION:Transthoracic echocardiography (TTE) is the method of choice for evaluation of prosthetic aortic valve function. The majority of studies reporting early and late hemodynamic performances after aortic valve replacement (AVR) with a bioprosthetic device are mainly based on echocardiographic examination at rest. A more accurate appraisal of bioprosthetic valves can be achieved by transthoracic echocardiographic evaluation under stress or under exercise conditions (ETTE), since, as often happens, normally and abnormally functioning biological aortic prostheses give similar gradients at rest echocardiographic examination. MATERIALS AND METHODS:With the aim of assessing the changes in hemodynamic behavior of a low-gradient bioprosthesis, we evaluated a consecutive series of 184 patients who received an aortic valve replacement using a stentless prosthesis at our institution between 2003 and 2010, a seven-year follow up. The assessment of transvalvular gradients, valve areas and left ventricular function was carried out by transthoracic echocardiography examination obtained at rest and under exercise at different steps, using a semi-supine exercise bicycle, managed by a single cardiologist. RESULTS:Mean transvalvular gradient increased from rest to maximum exercise by 3,81mmHg without significant difference as regard to the implanted valve size. Interestingly, the indexed valve area increased during exercise from 1.05cm2 to 1.10cm2. CONCLUSIONS:Use of exercise echocardiography represents a very helpful tool in the decision process for the choice of the most appropriate aortic valve substitute. Notably, stentless aortic bioprostheses demonstrated to achieve excellent hemodynamic features at rest and under exercise over time.
INTRODUCTION:Revision anterior cruciate ligament (ACL) reconstruction remains a clinical challenge, with high failure rates compared to primary procedures. The use of an internal brace (IB) as augmentation has been proposed to enhance stability and improve functional outcomes.1 The purpose of this article is to compare the clinical and radiological outcomes of revision ACL reconstruction using hamstring autograft from the contralateral leg, with and without an internal brace, at 24 months postoperatively.2 Materials and Methods: Thirty patients undergoing revision ACL reconstruction were randomized into two groups: Group A (n=15) underwent hamstring autograft reconstruction with IB augmentation, while Group B (n=15) received hamstring autograft alone. Clinical assessments included the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain.3 KT-1000 arthrometry measured anterior tibial translation.4 Magnetic resonance imaging (MRI) signal intensity was analyzed to assess graft maturation.5 Results: Group A demonstrated superior postoperative IKDC (88.7 ± 4.2 vs. 82.5 ± 5.1, p<0.01),6 Lysholm (91.4 ± 3.8 vs. 85.2 ± 4.3, p<0.01)7, and Tegner scores (7.2 ± 1.1 vs. 6.5 ± 1.3, p=0.03).8 VAS pain was significantly lower in Group A (1.3 ± 0.7 vs. 2.1 ± 0.8, p=0.02).9 KT-1000 demonstrated reduced anterior laxity in Group A at 24 months (2.5mm vs. 3.7mm, p<0.01).10 MRI analysis showed faster graft maturation in the IB group.11 Graft re-rupture occurred in one patient (6.7%) in Group A versus four patients (26.7%) in Group B (p=0.04).12 Conclusion: Internal bracing in revision ACL reconstruction provides enhanced knee stability, improved functional outcomes, and reduced re-rupture rates at 24 months.13.
Autologous skin grafting is the gold standard for managing acute and chronic wounds that cannot close via primary or secondary intention. Graft harvesting is most frequently performed using a dermatome, although alternative techniques, such as punch or pinch grafting, fractional epidermal grafting, suction bullae grafting, minced skin grafting, and skin cell suspensions also carry unique advantages depending on wound and patient characteristics. While these procedures have traditionally been performed in an operative setting, the morbidity associated with lengthy procedure times, general anesthesia, inpatient admission, and donor site pain and scarring have led clinicians to explore the viability of office-based approaches for smaller wounds amenable to autologous grafting. Here, we discuss the history, indications, and limitations of autologous skin grafting, the various techniques used for grafting, and the different devices and products both historically and currently on the market that may facilitate a less-invasive and costly approach to autologous skin grafting in an office-based setting.
INTRODUCTION:While arthroscopic TFCC debridement (TFCC-D) has proven successful for the treatment of pathological tears, a subset of patients may present with persistent or recurrent ulnar-sided wrist pain and require revision debridement, repair, and/or ulnar shortening osteotomy (USO). We present a retrospective comparative study that evaluates the clinical outcomes of 83 patients who underwent TFCC-D (N=17) or TFCC-D+USO (N=66). MATERIALS AND METHODS:Preoperative ulnar variance was measured on standard posteroanterior (PA) view and gripping PA view radiographs. Clinical outcomes at final follow up included visual analog scale (VAS) pain scores, grip and pinch strength recovery, active wrist range of motion, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient Rated Wrist Evaluation (PRWE) questionnaires. RESULTS:We report on 83 cases, mean age 45 years (range, 18-74 years), who underwent surgery between September 2016 and March 2020. Mean follow-up time was 93 weeks (range, 49-237 weeks). Mean VAS scores decreased from 7.4 to 5.3 in the TFCC-D group and from 6.7 to 2.9 in the TFCC-D+USO group. Patients in the TFCC-D group reported significantly higher QuickDASH (44.6 vs. 17.0) and PRWE scores (76.8 vs. 30.7) compared to the TFCC-D+USO group. Nine TFCC-D cases were indicated for revision compared with one TFCC-D+USO case. Eight of the nine TFCC-D cases indicated for revision exhibited positive ulnar variance on gripping PA view. CONCLUSIONS:Patients treated with TFCC-D+USO reported superior outcomes to those treated with TFCC-D alone on the basis of pain scores, QuickDASH and PRWE scores, and need for revision surgery.
The demand for safe and effective surface disinfection solutions in the perioperative has led to the development of technologies beyond traditional chemical disinfectants, which are often associated with limitations including improper application, harmful residues, and environmental risks. Ultraviolet C (UVC) light has emerged as a powerful, chemical-free, and reusable alternative capable of neutralizing a wide range of pathogens without leaving residual contaminants. Despite its potential, conventional UVC technologies face limitations, including inconsistent coverage, user-dependent efficacy, and safety concerns related to exposure times. This paper provides a comprehensive comparison of various UVC disinfection technologies, highlighting their unique features, applications, and limitations in the perioperative period. Among these, the UVCeed Mobile UVC Disinfection Device (UVCeed, LLC, Effingham, Illinois) stands out as a novel innovation that transcends the capabilities of traditional UVC tools. By integrating cutting-edge augmented reality (AR), artificial intelligence (AI), and gamification, UVCeed enhances user safety, optimizes disinfection accuracy, and ensures an intuitive, engaging experience. Its real-time visual feedback and intelligent exposure control address the critical gaps in earlier UVC technologies. UVCeed's transformative approach sets a new benchmark in surface disinfection, offering unparalleled effectiveness, user-friendliness, and environmental sustainability across healthcare, consumer, and industrial applications.
INTRODUCTION:Access to a patient's surgeon has become increasingly difficult given increased volumes of total joint arthroplasty (TJA). A surgeon-specific conversational chatbot has the theoretical advantage of engaging and guiding patients through the perioperative journey irrespective of surgeon availability. The purpose of this study was to retrospectively assess if enrollment in a perioperative chatbot was associated with improved outcomes following TJA compared to a historical cohort not enrolled. MATERIALS AND METHODS:We identified 1,338 TJA patients who enrolled in a Short Message Service (SMS) chatbot from 2020-2022 with greater than three months of follow up. Similarly, we identified a historical cohort of 1703 patients not enrolled in the SMS chatbot. The associations of chatbot enrollment on emergency department visits and readmissions within 30 and 90 days postoperatively were analyzed. RESULTS:Chatbot enrollment was associated with a significantly decreased odds ratios of emergency department visits at 30 and 90 days postoperatively (0.40 and 0.45 respectively, p<0.0001) compared to a historical cohort not enrolled. There was also a significantly decreased odds ratio of readmission by 90 days postoperatively (0.60, p=0.0168) for those enrolled in the SMS chatbot. CONCLUSIONS:Chatbot enrollment was associated with decreased odds ratios of emergency department visits and readmissions following TJA compared to a historical cohort without access to a perioperative chatbot. Perioperative chatbots may provide an opportunity to further improve patient outcomes following TJA.
INTRODUCTION:Cemented kinematic alignment (KA) total knee arthroplasty (TKA) is popular due to its superior patient-reported outcome scores (PROs). A new cementless version of a KA-optimized implant is available. The femoral component features a 20° trochlear groove and medial spherical articulation. The tibial insert features a medial socket, creating native anterior-posterior stability and a lateral flat articular surface promoting native medial pivot rotation. The present study aimed to determine whether clinical outcomes for patients receiving the cementless KA-optimized implant are equivalent to those receiving the cemented version after six weeks. This comparison is essential because lower PROs could indicate delayed osteointegration of the components, like dysfunction associated with delayed fracture union. MATERIALS AND METHODS:The study included 95 cementless KA TKAs matched 1:1 with 95 cemented KA TKAs based on surgery date, age, preoperative knee deformity, sex, and surgeon. Patients completed the Oxford Knee Score (OKS) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) both preoperatively and at six weeks, as well as the Forgotten Joint Score (FJS) at six weeks. A Wilcoxon two-sided equivalence test was used to test the null hypothesis that results were comparable for the cementless and cemented KA TKAs. RESULTS:The analysis included 114 females and 76 males, with a mean age of 68 years and a body mass index (BMI) of 31kg/m². Preoperatively and at six weeks, the age, sex distribution, BMI, knee extension and flexion, OKS, and KOOS JR scores for cementless and cemented KA TKAs were equivalent. At six weeks, the FJS scores were also equivalent. CONCLUSION:The KA-optimized implant closely resembling native knee morphology did not show evidence of delayed osteointegration. After six weeks, knee motion and PROs were equivalent to those of the cemented implants. However, longer-term monitoring of this new cementless implant is necessary.
INTRODUCTION:There is a wide range of nonoperative options to manage symptomatic knee osteoarthritis (OA). This paper aimed to 1) define the treatment sequence for patients undergoing up to four subsequent rounds (i.e., cryoneurolysis) of superficial (Cryo-Superficial) and/or deep genicular nerves (Cryo-Deep/Both), intra-articular corticosteroid injections (IA-CS), triamcinolone extended-release (IA-TA-ER), hyaluronic acid (IA-HA), or non-steroidal anti-inflammatory drugs (IA-NSAIDs); 2) compare usage of extended-release versus standard corticosteroid injections; and 3) quantify distribution of repeated treatments. MATERIALS AND METHODS:We identified 502 patients with symptomatic knee OA and received nonoperative intervention within the Innovations in Genicular Outcomes (IGOR) registry from 2021 to 2024. Treatment journey during follow up was presented aggregating baseline patient demographics, along with sequence of nonoperative treatments per patient, duration, and frequency of repeated use. Repeated use of Round 1 treatment for subsequent treatment rounds was estimated with descriptive statistics. RESULTS:Fifty-three percent of patients received only the original Round 1 treatment option, either single/repeated dose and did not receive any alternative treatment. Seventy-three percent of patients treated with intra-articular extended-release triamcinolone (IA-TAER) repeated the treatment at least once, whereas 60% of those treated with other treatments did so. No adverse events were reported in patients during repeated treatments. CONCLUSION:Patients who received IA-TAER were more likely to repeat the same injection, with 73% repeating at least once and no adverse events were attributed to repeated injections. Approximately half of the patients have switched from the initial treatment offered during follow up, with the use of IA-TAER associated with higher rates of repeated treatment. Significance and Innovation 1. Our study used a newly developed real-world registry IGOR to characterize treatment progression for patients with symptomatic knee OA undergoing up to five rounds of nonoperative treatment. 2. Non-surgical interventions included cryoneurolysis, intra-articular injections of NSAIDs, hyaluronic acid injections, corticosteroid, or extended release steroid (triamcinolone) injections. 3. We found 73% of patients treated with intra-articular extended-release steroid injections repeated treatment at least once, relative to 60% by other treatments. 4. We found approximately half of patients switched from initial treatment offered during follow up, with the use of IA-TAER associated with higher rates of repeated treatment.
Introduction: A portable medical rehabilitation device with adaptive telemedicine technology provides an adjunct therapy following total knee arthroplasty (TKA). The physician-monitored internet-based interface allows for physician-directed or free use of the portable medical rehabilitation device by the patient. The purpose of this study was to characterize patients’ satisfaction with its use, as well as its impact on perioperative range of motion (ROM). Materials and Methods: After institutional review board (IRB) approval, patients who used the portable rehab device postoperatively completed a 12-question survey that assessed use and satisfaction metrics at their six-week postoperative visit. Range of motion (ROM) at their six-week postoperative visit was analyzed against their survey responses. A total of 101 patients (42 men, 58 women, one preferred not to answer; 101 knees) were available for analysis, with a mean patient age of 68 years (range 48–84 years). Results: Overall satisfaction was 93%, with 14.9% noted “helpful,” 45.5% “strongly helpful,” and 32.7% “very strongly helpful.” Insurance covered the cost in 72%, while 23% paid for their device out of pocket with minimal impact, and 5% felt the out-of-pocket cost to be not worthy of the benefit. Nearly all (96%) of the patients stated they would recommend the device. Patients reported using their portable medical rehabilitation device for approximately two to three weeks (39.6%), two to three times per day (65.3%), and 11 to 15 minutes per session (69.3%). Older patients had lower usage than younger patients (p<0.001), and men trended toward higher usage than women (p=0.055). Mean six-week postoperative knee ROM was a 0–111° arc of motion. Change in ROM was not found to correlate with duration of use (p=0.385). Conclusion: The portable medical device is an option for rehabilitation after TKA with high patient satisfaction and low-cost burden, while achieving an appropriate arc of motion by six weeks following TKA. Further comparative investigations will be needed to determine the optimal duration of use following TKA.
Surgical site infections (SSIs) remain a significant complication in modern healthcare, particularly in orthopaedic surgery, where implants carry potential risk of contamination with biofilm formation. Traditional disinfection methods, such as chemical agents or ultraviolet-C (UVC) devices, carry limitations and may not ensure consistent and comprehensive anti-microbial effects. To this end, a novel technology UVCeed, an advanced disinfection system integrating artificial intelligence (AI), augmented reality (AR), and gamification, offers a promising solution to improve infection control within the operating room (OR). This narrative review explores the application of UVCeed technology in surgical environments, with a special focus on orthopaedic surgery. The paper discusses the unique advantages of UVCeed to enhancing surface sterilization, mitigating airborne contaminants, and overall augmenting existing infection control protocols. By leveraging real-time feedback mechanisms and intelligent dose optimization, UVCeed serves as an advancement in the approach to perioperative surgical disinfection.
INTRODUCTION:The purpose of this article is to describe a standardized approach for creating a physician-modified endovascular graft (PMEG) based on the Zenith Flex® (Cook Medical Inc., Bloomington, Indiana) platform. TECHNIQUE:A sterile template is constructed based on computed tomography angiography (CTA) measurements. Once the Zenith Flex® bifurcated endograft is desheathed, the template is placed over the device and adjusted so that the planned fenestrations do not overlap with the struts. The fenestration locations are marked on the fabric of the endograft and created using high-temperature cautery. The distal part of a snare is obtained, braided around a modified angiometer with a diameter matching the fenestration, and secured around the corresponding fenestration with locking sutures. Diameter-reducing ties are added by first securing a suture loop at the 12 o'clock position of each Z-stent, then the trigger wire is repositioned to the outside of the endograft at the 6 o'clock position and threaded through each of the loops to constrain the Z-stents. The endograft is reloaded through the peel-away sheath and is ready for the procedure. CONCLUSION:A PMEG with diameter-reducing ties and reinforced fenestrations can be constructed in a standardized fashion using the Zenith Flex® platform, providing an endovascular treatment option for complex abdominal aortic aneurysms when custom-made endografts are unavailable. CLINICAL IMPACT:Fenestrated endovascular aortic repair is an important treatment option for complex abdominal aortic aneurysms. However, custom-made fenestrated devices may not be available in all regions or medical centres, and their use is limited in urgent situations. Familiarity with constructing a physician-modified endovascular graft can provide patients with an endovascular treatment option in such situations. This step-by-step guide to constructing a physician-modified endovascular device based on the Zenith Flex® platform can help surgeons create a bespoke fenestrated device with diameter-reducing ties and reinforced fenestrations in a standardized fashion within a matter of hours.
INTRODUCTION:A surgeon performing kinematically aligned total knee arthroplasty (KA TKA) through a mid-vastus approach can use an insert goniometer to select the optimal insert thickness. The insert goniometer provides the value of soft-tissue-driven tibial internal rotation during passive knee flexion. This study tested whether the insert goniometer can identify one insert thickness that maximizes tibial rotation while restoring full knee extension during KA TKA performed through a medial parapatellar approach. MATERIALS AND METHODS:One surgeon trialed goniometer inserts from a 10 to 14mm thickness with a medial ball-in-socket and flat lateral articular conformity in 33 patients treated with unrestricted caliper-verified KA, PCL retention, and a medial parapatellar approach. The medial insert had markings that measured tibial orientation relative to a sagittal line on the femoral trial component at full extension and 90° flexion (+ external/ - internal). The difference of tibial external orientation in extension and tibial internal orientation at 90° flexion computed tibial internal rotation. RESULTS:Of the 33 TKAs, a 10mm (N =13) or 14mm thick (N =2) insert maximized tibial internal rotation. In these TKAs, a 1mm thinner or thicker liner was not trialed, respectively. The remaining liner thicknesses maximizing tibial rotation were 11mm in 12 TKAs, 12mm in four TKAs, and 13mm in two TKAs. Mean ± SD maximal tibial rotation was 17 ± 4.1°, which was 4° more than with a 1mm thinner (13 ± 5°) and 1mm thicker (13 ± 5.3°) insert (p<0.001). CONCLUSIONS:Surgeons performing KA TKA through a medial parapatellar approach can utilize the insert goniometer to select the insert thickness that maximizes tibial rotation. Maximizing tibial rotation with a medial ball-in-socket and lateral flat insert conformity restores physiologic knee kinematics and dynamically stabilizes the patella.
