Abstract:

Previous studies have shown that the accuracy of computer-assisted surgery (CAS) via computed tomography (CT) free systems is useful when applied in the clinical realm. However, few studies have compared CAS systems to the current gold standard, manually applied measuring guides. Thirty total knee arthroplasties (TKA) were performed on artificial Sawbones knees using three different navigational systems. The TKAs were performed by a fellowship-trained joint reconstruction surgeon as well as a third- and a fourth-year orthopedic resident to assess differences in performance with regard to surgical experience. Using a two-way multivariate analysis of variance (MANOVA), no statistical differences were found in the accuracy of each of the three CAS navigational systems. Similarly, no differences were found between the accuracy of CAS systems and the gold standard measuring method. No differences in performance were found between the orthopedic residents and the fellowship-trained surgeon, suggesting a relatively small learning curve and usability. Definitive assessment of the clinical efficacy should be further assessed in a cadaveric study or, ideally, by way of a randomized clinical trial.

Authors:

Amy E. Abbot, M.D., M.S., Sports Medicine and Arthroscopy Fellow, Department of Orthopedic Surgery, University of Massachusetts, Worchester, Worchester, Massachusetts, USA, Byung-Hoon Ko, M.S. Korea Advanced Institute of Science and Technology, Daejeon, Korea, Niket Shrivastava, M.D., Orthopedic Resident, Center for Hip and Knee Replacement, Department of Orthopedic Surgery, New York Presbyterian Hospital, at Columbia University New York, New York, USA, Yong-San Yoon, Ph.D., Korea Advanced Institute of Science and Technology, Daejeon, Korea, Thomas R. Gardner, M.C.E., Center for Orthopedic Research, Department of Orthopedic Surgery, New York Presbyterian Hospital at Columbia University, New York, New York, USA, William Macaulay, M.D., Director, Center for Hip and Knee Replacement (CHKR), Director, CHKR Clinical Fellowship, Advisory Dean, Columbia University College of Physicians and Surgeons, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, New York Presbyterian Hospital at Columbia University, New York, New York, USA

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Abstract:

In this chapter, we review current techniques employed to decrease blood loss and describe the effective use of a unique bipolar electrocautery device in a patient with neuromuscular scoliosis undergoing posterior spinal fusion (PSF). The reduction of blood loss and subsequent elimination of allogeneic blood transfusion is a desired outcome in all surgeries and is a major concern during PSF. In the child or adolescent with neuromuscular scoliosis, this becomes a greater concern due to a variety of factors such as the inability of the musculature to compress blood vessels, extensive surgical exposure, and the duration of the operation. A multitude of pharmacological, anesthetic, and surgical techniques-including preoperative autologous blood donation and human recombinant erythropoietin, intraoperative blood salvage techniques, and topical and systemic hemostatic agents-are employed to reduce the need for transfusion. Many of these techniques carry their own risks and, thus far, a systematic approach has not been established to decrease the need for transfusion. In the continued pursuit of reducing intraoperative blood loss, other surgical techniques must be developed.

Authors:

Amer F. Samdani, M.D., Staff Surgeon, Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA, Andrew Torre-Healy, B.S. Student, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA, JahanGir Asghar, M.D., Spine Fellow, Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA, Andrew M. Herlich, M.D., Anesthesiologist, Temple University Hospital, Philadelphia, Pennsylvania, USA, Randal R. Betz, M.D. Chief of Staff, Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA

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Abstract:

Midflexion instability is a new concept associated with revision total knee arthroplasty. It appears as rotational instability with combined external rotation and valgus stress in a knee flexed between 45° and 90°. Three main factors contribute to this instability: anterior medial collateral ligament attenuation, femoral-tibial articular geometry, and tibial post-femoral box geometry. Rotational stress should be included when assessing stability intraoperatively to identify those patients who may require additional constraint.

Authors:

Edward J. McPherson, M.D., F.A.C.S., Director, Los Angeles Orthopaedic Institute, Los Angeles, California, USA, John Cuckler, M.D., Professor and Director, Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA, Adolph V. Lombardi, Jr., M.D., F.A.C.S., Senior Associate, Joint Implant Surgeons, Inc., New Albany, Ohio, USA, Clinical Assistant Professor, Department of Orthopaedics, Ohio State University, Columbus, Ohio, USA, Clinical Assistant Professor, Department of Biomedical Engineering, Ohio State University, Columbus, Ohio, USA, President of Medical Staff Services, Mount Carmel New Albany Surgical Hospital, New Albany, Ohio, USA

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Abstract:

This study directly compared a minimally invasive dual-incision muscle-sparing surgical technique with a standard posterolateral approach in total hip arthroplasty to assess for early complications, clinical success, and alignment. Total hip arthroplasties using a minimally invasive, muscle-sparing, dual-incision approach were performed on 21 hips (20 patients). This cohort was compared to a contemporaneously performed group of 21 hips (20 patients) using a standard posterolateral approach. Five complications were reported for the dual-incision group versus one complication for the posterolateral group. Postoperative radiographic alignment of the prosthesis was closer to optimal for the posterolateral group. The dual-incision group had longer operating times and a significant increase in complications. The authors have discontinued the use of this technique based on the results of this study.

Authors:

Frank R. Kolisek, M.D., Director, Joint Replacement Center at St. Francis Hospital, OrthoIndy, Indianapolis, Indiana, USA, Thorsten M. Seyler, M.D. , Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA, Slif D. Ulrich, M.D. Fellow, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA, David R. Marker, B.S., Medical Student, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA, Nenette M. Jessup, M.P.H., Research Assistant, Joint Replacement Center at St. Francis Hospital, OrthoIndy, Indianapolis, Indiana, USA, Michael A. Mont, M.D., Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA

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Abstract:

This chapter evaluates the current evidence on common minimally invasive therapeutic spinal procedures based on the Levels of Evidence and Grades of Recommendation developed by the Centre for Evidence-Based Medicine (Oxford, United Kingdom). The results of the evaluation of current clinical evidence allow the following recommendations to be made: epidural adhesiolysis performed repeatedly every 3 months to 4 months is effective in the "post lumbar laminectomy" syndrome; epidural steroid injections may provide only short-term relief from pain in lumbar radiculopathy but have no long-term effect; selective nerve root injections of corticosteroids have no therapeutic effect on the long-term natural history of radiculopathy symptoms; intra-articular facet joint injections of corticosteroids have no therapeutic effect on lower back pain (grade of recommendation: A). Furthermore, percutaneous vertebroplasty and balloon kyphoplasty provide immediate pain relief from osteoporotic spinal fractures but no significant long-lasting benefit (grade of recommendation: B). Finally, there is limited evidence (grade of recommendation: C) of the value of medial branch (facet) neurotomy, sacroiliac joint injection of steroids, and intradiscal electrothermal therapy, as well as of the advantages of percutaneous endoscopic lumbar discectomy over open microdiscectomy. As the level of evidence is generally low, more prospective randomized-controlled studies are needed to establish the value of the considered methods.

Authors:

Ioannis A. Karnezis, M.D., M.Sc., F.E.B.O.T., F.R.C.S. (Orth.), Consultant Orthopedic and Spinal Surgeon, Director of the Scientific Committee, Back Care Network, Athens, GREECE

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Abstract:

The anterior endoscopic cervical microdecompression (AECM) of disc and foramen with added application of nonablative lower holmium laser energy for disc shrinkage (laser thermodiskoplasty) has proven to be safe, less traumatic, easier, and more efficacious than conventional methods with significant economic savings. It preserves spinal motion and provides a channel for spinal arthroplasty. It is an effective alternative or replacement for conventional open cervical spinal surgery for discectomy, and can decompress spinal stenosis and degenerative spine conditions.

Authors:

John C. Chiu, M.D., D.Sc., F.R.C.S., Director, Department of Neurospine Surgery, Department of Neurospine Surgery, California Center for Minimally Invasive Spine Surgery, California Spine Institute Medical Center, Thousand Oaks, California, USA

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Abstract:

The risk of perioperative complications while adopting minimally invasive spine surgery techniques may slow the acceptance of this technology. We assess the perioperative complication rate with minimally invasive single- and two-level interbody fusions and compare this incidence with a contemporaneous cohort of open single- and two-level open interbody fusions, with all procedures completed by a single surgeon in a single practice group. We compiled all open and MIS interbody fusion cases completed during the study period. Sofamor-Danek X-Tube™ and Stryker Luxor™ minimally invasive systems were used on all patients. Medical records were reviewed to assess any adverse events occurring in the perioperative period. Care was taken to include all medical and surgical adverse events and complications occurring within 30 days of surgery. Over the study period, 28 minimally invasive lumbar fusions were identified: 24 single- and 4 two-level cases. Both TLIF and PLIF techniques were used. This cohort was compared with a group of 19 single- and two-level open interbody fusion cases completed over the same period. The complication rate for the MIS cohort was 18%, with 7 complications occurring in 5 patients. In the open group, 8 complications occurred in 7 patients, an incidence of 37%. A standard distribution of complications occurred, and the difference between the two groups was not statistically significant. Limiting our analysis to severe complications yielded rates of 7% and 21% for the two groups, also not significantly divergent. Perioperative complications are not more common in well-selected MIS patients. Allowing for proper patient selection, MIS techniques have a favorable complication profile.

Authors:

Bradley Bagan, M.D., Resident, Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, Nimesh Patel, M.D. Resident, Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, Harel Deutsch, M.D., Assistant Professor, Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, James Harrop, M.D., Assistant Professor, Department of Neurosurgery, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania, Ashwini Sharan, M.D., Assistant Professor, Department of Neurosurgery, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania, Alexander R. Vaccaro, M.D., Professor, Department of Orthopedic Surgery, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania, John K. Ratliff, M.D., Assistant Professor, Department of Neurosurgery, Rush University Medical Center, and Chicago, Illinois, Department of Neurosurgery, Thomas Jefferson University Medical Center, Philadelphia, Pennsylvania

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Abstract:

Until relatively recently, few procedures have been developed that restore significant motor and sensory function in individuals with obsolete (ie, chronic), complete spinal cord injury (SCI). Building upon the methodology used to treat brachial root avulsion, the authors have developed peripheral nerve-rerouting procedures that have restored some function in hundreds of patients with such SCI. Many of the treated patients have regained life-enhancing function depending upon their injury level, such as walking with assistive devices, partial hand function, urination, sexual sensation, etc. Although sophisticated surgeries, the basic concept is theoretically simple: a functional nerve from above the injury site is rerouted and connected to a paralysis-affected peripheral nerve below the injury site. This Chapter summarizes more than a dozen rerouting procedures, which restore function that range from breathing to toe sensation. This summary discusses the indications and criteria for choosing the best donor nerve based on the specific injury level, and emphasizes major procedural features such as the use of selected interfascicular anastomosis, modified end-to-side suture techniques, vascularized donor nerves, a muscle trigger for the synchronized contraction of congenerous muscles, and reconstruction procedures to restore donor-nerve function.

Authors:

ShaoCheng Zhang, M.D., Professor, Department of Orthopedics, Changhai Hospital, Shanghai, China, Yan Wang, M.D., Professor and Chairman, General Hospital of PLA, Beijing, China, Laurance Johnston, Ph.D., Consulting Scientist, Paralyzed Veterans of America, Washington, DC, USA, Iceland/WHO Project on Spinal Cord Injury, Reykjavik, Iceland

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