International multicentre review of perioperative management and outcome for catecholamine-producing tumours.

BACKGROUND: Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected. METHODS: Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality. RESULTS: Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients. CONCLUSION: There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

ANTECEDENTES: La cirugía de los tumores productores de catecolaminas puede complicarse por la inestabilidad hemodinámica intraoperatoria y postoperatoria. Se han propuesto distintas estrategias de manejo perioperatorio, pero ninguna ha sido evaluada en ensayos aleatorizados. Para evaluar este tema, se han recogido los datos de los resultados y del manejo perioperatorio contemporáneo de 21 centros. MÉTODOS: Veintiún centros aportaron datos de los resultados de los pacientes operados por feocromocitoma y paraganglioma entre 2000-2017. Los datos incluyeron el número de pacientes con y sin bloqueo del receptor α, las técnicas quirúrgicas y anestésicas, las complicaciones y la mortalidad perioperatoria. RESULTADOS: Los centros en su conjunto aportaron datos de 1.860 pacientes con feocromocitoma y paraganglioma, de los cuales 343 pacientes fueron intervenidos sin bloqueo del receptor α. La gran mayoría (79%) de las cirugías se realizaron utilizando técnicas mínimamente invasivas, incluido un 17% de procedimientos con preservación de la corteza suprarrenal. La tasa de complicaciones cardiovasculares fue de 5,0% en total; 5,9% (90/1517) en pacientes con bloqueo preoperatorio de los receptores α y 0,9% (3/343) en pacientes no pretratados. La mortalidad global fue del 0,5% (9/1860); 0,5% (8/1517) en pacientes pretratados y 0,3% (1/343) en pacientes no tratados previamente. CONCLUSIÓN: Existe una variabilidad sustancial en el manejo perioperatorio de los tumores productores de catecolaminas, aunque la tasa global de complicaciones es baja. Este estudio brinda la oportunidad para efectuar comparaciones sistemáticas entre estrategias de prácticas terapéuticas variables. Se necesitan más estudios para definir mejor el enfoque de manejo óptimo y parece conveniente volver a evaluar las guías internacionales perioperatorias.

Alternative Reimbursement Models: Bundled Payment and Beyond: AOA Critical Issues.

The Bundled Payments for Care Improvement (BPCI) initiative was begun in January 2013 by the U.S. Centers for Medicare & Medicaid Services (CMS) through its Innovation Center authority, which was created by the U.S. Patient Protection and Affordable Care Act (PPACA). The BPCI program seeks to improve health-care delivery and to ultimately reduce costs by allowing providers to enter into prenegotiated payment arrangements that include financial and performance accountability for a clinical episode in which a risk-and-reward calculus must be determined. BPCI is a contemporary 3-year experiment designed to test the applicability of episode-based payment models as a viable strategy to transform the CMS payment methodology while improving health outcomes. A summary of the 4 models being evaluated in the BPCI initiative is presented in addition to the awardee types and the number of awardees in each model. Data from one of the BPCI-designated pilot sites demonstrate that strategies do exist for successful implementation of an alternative payment model by keeping patients first while simultaneously improving coordination, alignment of care, and quality and reducing cost. Providers will need to embrace change and their areas of opportunity to gain a competitive advantage. Health-care providers, including orthopaedic surgeons, health-care professionals at post-acute care institutions, and product suppliers, all have a role in determining the strategies for success. Open dialogue between CMS and awardees should be encouraged to arrive at a solution that provides opportunity for gainsharing, as this program continues to gain traction and to evolve.

Update on Biomaterials.

Biomaterials are essential to the use and development of successful treatments for orthopaedic patients. Orthopaedic surgeons need to understand the expected clinical performance and the effects of implants in patients. Recent attempts to improve implant durability have resulted in adverse effects related to biomaterials and their relationship to patients. Examples of these adverse effects in hip arthroplasty include wear and corrosion of metal-on-metal bearings, trunnions, and tapered modular neck junctions. Conversely, polymers and ceramics have shown substantial improvements in durability. Improved implant compositions and manufacturing processes have resulted in ceramic head and acetabular liners with improved material properties and the avoidance of voids, which have, in the past, caused catastrophic fractures. Cross-linking of polyethylene with radiation and doping with antioxidants has substantially increased implant durability and is increasingly being used in joint prostheses other than the hip. Additive manufacturing is potentially a transformative process; it can lead to custom and patient-specific implants and to improvements in material properties, which can be optimized to achieve desired bone responses. Orthopaedic surgeons must understand the material properties and the biologic effects of new or altered biomaterials and manufacturing processes before use. In addition, a clear benefit to the patient must be proven based on superior preclinical results and high-quality clinical investigations before orthopaedic surgeons use new or altered biomaterials.

Preclinical computational models: predictors of tibial insert damage patterns in total knee arthroplasty: AAOS exhibit selection.

Computational models that predict clinical surface damage of the tibial insert during activities of daily living are emerging as powerful tools to assess the safety and efficacy of contemporary total knee arthroplasty designs. These models have the advantage of quickly determining the performance of new designs at low cost, and they allow direct comparison with the performance of classic, clinically successful designs. This study validated finite element and kinematic modeling predictions through comparison with preclinical physical testing results, damage patterns on retrieved tibial inserts, and clinically measured knee motion. There is a mounting body of evidence to support the role of computational modeling as a preclinical tool that enables the optimization of total knee arthroplasty designs and the auditing of component quality control before large-scale manufacturing is undertaken.

Biomechanical properties of fixed-angle volar distal radius plates under dynamic loading.

PURPOSE: To evaluate and compare the biomechanical properties of 8 different locked fixed-angle volar distal radius plates under conditions designed to reflect forces seen in early fracture healing and postoperative rehabilitation. METHODS: We evaluated the Acumed Acu-Loc (Acumed, Hillsboro, OR), Hand Innovations DVR (Hand Innovations, Miami, FL), SBi SCS volar distal radial plate (Small Bone Innovations, Morrisville, PA), Synthes volar distal radius plate and EA extra-articular volar distal radius plate (Synthes, Paoli, PA), Stryker Matrix-SmartLock (Stryker Leibinger, Kalamazoo, MI), Wright Medical Technology Locon VLS (Wright Medical Technology, Arlington, TN), and Zimmer periarticular distal radius locking plate (Zimmer, Warsaw, IN). After affixing each plate to a synthetic corticocancellous radius, we created a standardized dorsal wedge osteotomy. Each construct had cyclic loading of 100 N, 200 N, and 300 N for a total of 6000 cycles. Outcomes, including load deformation curves, displacement, and ultimate yield strengths, were collected for each construct. RESULTS: The Wright plate was significantly stiffer at the 100 N load than the Zimmer plate and was stiffer at the 300 N load than 4 other plates. The Zimmer and Hand Innovations plates had the highest yield strengths and significantly higher yield strengths than the Wright, SBi, Stryker, and Synthes EA plates. CONCLUSIONS: Given the biomechanical properties of the plates tested, in light of the loads transmitted across the native wrist, all plate constructs met the anticipated demands. It seems clear that fracture configuration, screw placement, cost, and surgeon familiarity with instrumentation should take priority in selecting a plating system for distal radius fracture treatment. CLINICAL RELEVANCE: This study provides further information to surgeons regarding the relative strengths of different plate options for the treatment of distal radius fractures.

Reporting and notification of adverse events in orthopaedics.

Surgeons should know how to alert the US FDA when an adverse event occurs with a device that has been approved by the FDA. Documentation of such events is critically important to help identify trends concerning a particular device, thereby helping surgeons and other health care professionals avoid similar events. The FDA created the MedWatch program to aid health care professionals in reporting adverse events. Orthopaedic surgeons can use the program to get up-to-date alerts and help protect their patients.

Clinical performance of highly cross-linked polyethylenes in total hip arthroplasty.

Aseptic loosening secondary to wear-debris-induced osteolysis has been identified as the leading cause of late failure of total hip arthroplasty. Highly cross-linked polyethylene acetabular liners were developed as one approach to reducing this wear. Preclinical laboratory wear testing showed a number of cross-linked polyethylenes to have dramatically less wear than the polyethylene that had been in use for several decades. After the initial bedding-in phase (one to two years), the percent reductions in the wear rate, as indicated by the amount of penetration of the head into the socket evident on serial radiographs, have been comparable with what was predicted from preclinical hip-simulator testing of the highly cross-linked polyethylenes. To our knowledge, there have been no reports of clinically relevant osteolysis that was clearly attributable to wear of a highly cross-linked polyethylene acetabular liner. However, the clinical performance of these materials should be closely monitored with long-term follow-up.

Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement.

Use of antibiotic-loaded bone cement for prophylaxis against infection is not indicated for patients not at high risk for infection who are undergoing routine primary or revision joint replacement with cement. The mechanical and elution properties of commercially available premixed antibiotic-loaded bone-cement products are superior to those of hand-mixed preparations. Use of commercially available antibiotic-loaded bone-cement products has been cleared by the United States Food and Drug Administration only for use in the second stage of a two-stage total joint revision following removal of the original prosthesis and elimination of active periprosthetic infection. Use of antibiotic-loaded bone cement for prophylaxis against infection in the second stage of a two-stage total joint revision involves low doses of antibiotics. Active infection cannot be treated with commercially available antibiotic-loaded bone cement as such treatment requires higher doses of antibiotics.

The Knee Society system of standardized abbreviations for surgery of the arthritic knee.

A new standardized system of abbreviations has been adopted by the Knee Society to bring clarity and brevity to scientific reports involving the arthritic knee. This system works by using a set of core abbreviations that are modified with prefixes, suffixes, and superscript notations to indicate succinctly the surgical approach, the procedure used, and the type of prosthesis implanted.