Influence of different position modal parameters on milling chatter stability of orthopedic surgery robots.

This research is dedicated to exploring the dynamics of milling chatter stability in orthopedic surgery robots, focusing on the impact of position modal parameters on chatter stability. Initially, we develop a dynamic milling force model for the robotic milling process that integrates both modal coupling and regenerative effects. We then employ the zero-order frequency domain method to derive a chatter stability domain model, visually represented through stability lobe diagrams (SLDs). Through conducting hammer test experiments, we ascertain the robot's modal parameters at varying positions, enabling the precise generation of SLDs. This study also includes experimental validation of the chatter SLD analysis method, laying the groundwork for further examination of chatter stability across different positional modal parameters. Finally, our analysis of the variations in modal parameters on the stability of robot milling chatter yields a theoretical framework for optimizing cutting parameters and developing control strategies within the context of orthopedic surgery robots.

A Look Forward and a Look Back: The Growing Role of ERAS Protocols in Orthopedic Surgery.

The success of enhanced recovery after surgery (ERAS) protocols in improving patient outcomes and reducing costs in general surgery are widely recognized. ERAS guidelines have now been developed in orthopedics with the following recommendations. Preoperatively, patients should be medically optimized with a focus on smoking cessation, education, and anxiety reduction. Intraoperatively, using multimodal and regional therapies like neuraxial anesthesia and peripheral nerve blocks facilitates same-day discharge. Postoperatively, early nutrition with appropriate thromboprophylaxis and early mobilization are essential. As the evidence of their improvement in patient outcomes and satisfaction continues, these pathways will prove invaluable in optimizing patient care in orthopedics.

Team-based digital communication reduced patient-initiated phone calls to the hospital and improved patient satisfaction after orthopedic surgery: a randomized controlled trial in 70 patients.

BACKGROUND AND PURPOSE: Post-discharge inquiries to the hospital are predominantly conducted through phone calls. The rigid timing of these calls is inconvenient for patients and disrupts the workflows of healthcare professionals. The aim of this study was to investigate the effect of a team-based digital communication intervention (eDialogue) facilitated through a messenger-like commercial solution on patient-initiated phone calls to the hospital after discharge. Secondarily, we investigated other patient-initiated contacts, patients' perception of continuity of care, and their perception of feeling safe and satisfied after hospital discharge. METHODS: On the day of discharge, 70 surgically treated orthopedic patients were randomized to the intervention group with access to eDialogue (n = 35) or the control group with standard communication pathways by phone call (n = 35) for the following 8 weeks. Through eDialogue, the intervention group had access to team-based asynchronous digital communication in text and photos with healthcare professionals across disciplines and sectors. Inclusion criteria were discharge to own home and receipt of rehabilitation services from both hospital and primary care after discharge. RESULTS: We found a significant reduction in the mean number of patient-initiated phone calls to the hospital from 2.3 (95% confidence interval [CI] 1.4-4.1) in the control group to 0.5 (CI 0.3-1.0) in the intervention group (P = 0.004). Across groups, patients reported similar perceptions of continuity of care; however, the participants in the intervention group expressed significantly improved perceptions of, and satisfaction with, access to healthcare after discharge. CONCLUSION: Access to eDialogue reduced patient-initiated phone calls to the hospital, enhanced patient satisfaction with healthcare accessibility, and did not compromise patients' perception of continuity of care after discharge compared with standard communication pathways.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery.

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients.

BACKGROUND: Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. METHODS: Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. RESULTS: POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. CONCLUSION: The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.

Allograft reconstruction of the medial patellofemoral complex in skeletally immature patients: a technical note.

Patellofemoral instability (PFI) is a common disorder in children and adolescents. Surgical stabilization of the patella poses challenges in skeletally immature patients due to anatomical peculiarities at this stage, leading to the absence of an established standard reconstruction technique. Recently, there has been a notable interest in the medial patellofemoral complex (MPFC), encompassing the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon femoral ligament (MQTFL), owing to their role in restricting lateral patellar displacement. This paper aims to describe the surgical technique employed by the author for reconstructing the medial patellofemoral complex with allograft in skeletally immature patients with patellofemoral instability. Study design: surgical technique.

La inestabilidad patelofemoral (PFI) es un trastorno común en niños y adolescentes. La estabilización quirúrgica de la rótula plantea desafíos en pacientes esqueléticamente inmaduros debido a peculiaridades anatómicas en esta etapa, lo que lleva a la ausencia de una técnica de reconstrucción estándar establecida. Recientemente, ha habido un interés notable en el complejo femororrotuliano medial (MPFC), que abarca el ligamento femororrotuliano medial (MPFL) y el ligamento femoral del tendón del cuádriceps medial (MQTFL), debido a su papel en la restricción del desplazamiento rotuliano lateral. Este artículo tiene como objetivo describir la técnica quirúrgica empleada por el autor para reconstruir el complejo femororrotuliano medial con aloinjerto en pacientes esqueléticamente inmaduros con inestabilidad femororrotuliana. Diseño del estudio: técnica quirúrgica.

Outcomes of surgical treatment of patellar instability in children with Down syndrome.

BACKGROUND: patellar instability is a relatively frequent musculoskeletal disorder in children with Down syndrome (DS). However, such a condition has seldom been studied in the literature, even less its surgical treatment. Different techniques have been offered for this condition; the evidence for surgical options is scarce and primarily based on case reports or case series with few patients and heterogeneous techniques. Given this background, we aimed to evaluate the outcomes of a uniform kind of surgical procedure for such a condition that combined lateral soft tissue release, medial patellofemoral ligament (MPFL) reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty (if needed). MATERIALS AND METHODS: This retrospective study involved 11 skeletally immature patients (12 knees; 9 males and 2 females), 5.5 to 14.1 years of age, with DS who had patellofemoral instability (PFI) and were managed by this technique between October 2018 and March 2020. Preoperative radiography, CT scan, and MRI were performed to evaluate the physis status, lower limb alignment, patellar height, trochlear morphology, and any associated knee pathology. A functional knee assessment was done by using the Kujala score and the modified Lysholm score. RESULTS: The mean time of follow-up (± SD) was 47.7 ± 5.8 months (range: 39-56). Pre-operatively, the Kujala score (± SD) was 52.6 ± 14.3 (range: (31-74), and at final follow-up, it was 92.2 ± 4.4 (range: (88-98), showing a significant improvement (P < 0.001). The preoperative modified Lysholm score (± SD) was 54.3 ± 8.1 (range: 39-62), and at final follow-up it was 92.4 ± 5.3 (range: 82-96), showing a significant improvement (P < 0.001). All patients had a stable patella without a recurrence of instability and regained full ROM. There was no incidence of a patellar fracture or femoral physis injury. CONCLUSIONS: Our proposed technique of combined soft tissue procedures, including lateral soft tissue release, MPFL reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty, was an effective method for treating patellar instability in children with DS while avoiding physeal injury and patellar fracture. Functional scores and radiological outcomes were improved. LEVEL OF EVIDENCE: IV; retrospective case series.

Robot-assisted retractor in spine surgery: Preliminary evaluation of its feasibility and two operation mode in beagles.

OBJECTIVE: To assess the feasibility of the robot-assisted retractor. To compare the muscle injury of the two operation modes, intermittent retraction mode and continuous retraction mode in the robot-assisted retractor to find a better robot operation mode. METHODS: A new robot-assisted retractor experimental platform was developed. Three incisions were made on the backs of three beagles. The robot-assisted retractor was used to retract the muscle on both sides of the incisions in intermittent retraction mode and continuous retraction mode, and the operation of the robot system was observed. The muscle samples were stained with hematoxylin-eosin (HE) to observe the muscle injury. The difference between the muscle injuries of the two groups was statistically compared using paired t test. RESULTS: The robot-assisted retractor can precisely retract to the specified position without malfunction or dangerous actions. Histologic evaluation showed that fewer muscle injury was found in the intermittent retraction mode group of the robot-assisted retractor compared to the continuous retraction mode group. CONCLUSION: The robot-assisted retractor offers a certain degree of feasibility and safety. The robot-assisted retractor is able to effectively reduce muscle injury with the intermittent retraction mode.

Deep Learning and Multimodal Artificial Intelligence in Orthopaedic Surgery.

This review article focuses on the applications of deep learning with neural networks and multimodal neural networks in the orthopaedic domain. By providing practical examples of how artificial intelligence (AI) is being applied successfully in orthopaedic surgery, particularly in the realm of imaging data sets and the integration of clinical data, this study aims to provide orthopaedic surgeons with the necessary tools to not only evaluate existing literature but also to consider AI's potential in their own clinical or research pursuits. We first review standard deep neural networks which can analyze numerical clinical variables, then describe convolutional neural networks which can analyze image data, and then introduce multimodal AI models which analyze various types of different data. Then, we contrast these deep learning techniques with related but more limited techniques such as radiomics, describe how to interpret deep learning studies, and how to initiate such studies at your institution. Ultimately, by empowering orthopaedic surgeons with the knowledge and know-how of deep learning, this review aspires to facilitate the translation of research into clinical practice, thereby enhancing the efficacy and precision of real-world orthopaedic care for patients.

Bupivacaine-fentanyl isobaric spinal anesthesia reduces the risk of ICU admission in elderly patients undergoing lower limb orthopedic surgery.

BACKGROUND: To evaluate if bupivacaine-fentanyl isobaric spinal anesthesia could reduce the risk of ICU admission compared with general anesthesia in elderly patients undergoing lower limb orthopedic surgery. METHODS: This study comprised a retrospective review of all lower limb orthopedic surgeries performed at our hospital between January 2013 and December 2019. According to anesthesia methods, patients were divided into the spinal anesthesia group (n = 1,728) and the general anesthesia group (n = 188). The primary outcome evaluated was the occurrence of ICU admission. Secondary outcomes included hemodynamic changes, postoperative complications, and mortality. RESULTS: Repeated measure analysis of variance indicated that the difference between the two groups in the systolic blood pressure (SBP) was not significant before anesthesia (T0), immediately after anesthesia (T1), and before leaving the operation room (T8) (P > 0.05), but significant (P < 0.01) from 5 min after anesthesia (T2) to after operation (T7). The proportions of ICU admission (6.4% vs. 23.8%, P < 0.01) and unplanned intubation (0.1% vs. 3.8%, P < 0.01) were significantly lower in the spinal anesthesia group compared with those in the general anesthesia group. Multivariate logistic regression revealed that after controlling for potential confounding factors, the odds of ICU admission for patients in the spinal anesthesia group was 0.240 times (95% CI 0.115-0.498; P < 0.01) than those in the general anesthesia group. CONCLUSIONS: Bupivacaine-fentanyl isobaric spinal anesthesia significantly reduced the risk of ICU admission and unplanned intubation, and provided better intraoperative hemodynamics in elderly patients undergoing lower limb orthopedic surgery. TRIAL REGISTRATION: This study has been registered in the Chinese Clinical Trial Registry (ChiCTR2000033411).

Functional outcomes and rates of return to sport activities in a non-athlete population after the open Brostrom-Gould repair: a seven-year follow-up.

INTRODUCTION: After an ankle sprain, up to 20% of patients may develop chronic lateral ankle instability (CLAI) requiring surgical treatment. The objective of this study was to investigate the functional outcomes and rates of return to sport activities in a cohort of non-athlete patients with chronic lateral ankle instability (CLAI) who underwent the opened Brostrom-Gould technique (BGT). MATERIALS AND METHODS: Seventy-nine patients (seventy-nine feet) from three different centers undergoing BGT were reviewed. For clinical and functional analysis, the AOFAS ankle-hindfoot scale was applied and rates of return to sport activities were assessed. Correlation of Δ-AOFAS and rates of return to sport activities with all variables analyzed was performed. RESULTS: Mean AOFAS score improved from 64.6 to 97.2 (p < 0.001). Sixty-one (77.2%) returned to preinjury activities and 18 (22.8%) changed to a lower-level modality. Symptoms of instability were related to Δ-AOFAS (p = 0.020). Change in the sport activity was related to pain and symptoms of instability (p = 0.41 and p < 0.001). CONCLUSION: Recreational athlete patients who underwent the BGT demonstrated excellent functional outcomes after a mean follow-up of 7 years. Residual pain and symptoms of instability after surgery were the main complaints associated with limitations in physical activities.

A discrete-event simulation model for assessing operating room efficiency of thoracic, gastrointestinal, and orthopedic surgeries.

BACKGROUND: In hospital management, pinpointing steps that most enhance operating room (OR) throughput is challenging. While prior literature has utilized discrete event simulation (DES) to study specific strategies such as scheduling and resource allocation, our study examines an earlier planning phase, assessing all workflow stages to determine the most impactful steps for subsequent strategy development. METHODS: DES models real-world systems by simulating sequential events. We constructed a DES model for thoracic, gastrointestinal, and orthopedic surgeries summarized from a tertiary Chinese hospital. The model covers preoperative preparations, OR occupation, and OR preparation. Parameters were sourced from patient data and staff experience. Model outcome is OR throughput. Post-validation, scenario analyses were conducted for each department, including: (1) improving preoperative patient preparation time; (2) increasing PACU beds; (3) improving OR preparation time; (4) use of new equipment to reduce the operative time of a selected surgery type; three levels of improvement (slight, moderate, large) were investigated. RESULTS: The first three improvement scenarios resulted in a 1%-5% increase in OR throughput across the three departments. Large reductions in operative time of the selected surgery types led to approximately 12%, 33%, and 38% increases in gastrointestinal, thoracic, and orthopedic surgery throughput, respectively. Moderate reductions resulted in 6%-17% increases in throughput and slight reductions of 1%-7%. CONCLUSIONS: The model could reliably reflect OR workflows of the three departments. Among the options investigated, model simulations suggest that improving OR preparation time and operative time are the most effective.

Thermal Damage in Orthopaedics.

There are numerous potential sources of thermal damage encountered in orthopaedic surgery. An understanding of the preclinical mechanisms of thermal damage in tissues is necessary to minimize iatrogenic injuries and use these mechanisms therapeutically. Heat generation is a phenomenon that can be used to a surgeon's benefit, most commonly for hemostasis and local control of tumors. It is simultaneously one of the most dangerous by-products of orthopaedic techniques as a result of burring, drilling, cementation, and electrocautery and can severely damage tissues if used improperly. Similarly, cooling can be used to a surgeon's advantage in some orthopaedic subspecialties, but the potential for harm to tissues is also great. Understanding the potential of a given technique to rapidly alter local temperature-and the range of temperatures tolerated by a given tissue-is imperative to harness the power of heat and cold. In all subspecialties of orthopaedic surgery, thermal damage is a relevant topic that represents a direct connection between preclinical and clinical practice.

Standing on shoulder of giants: the incredible legacy of the Judet family in orthopaedic surgery.

In orthopaedic surgery, as well as other areas in medicine, it is common for a surgical technique to carry the original authors' name describing the procedure. The Judet family represents a unique history, since several orthopaedic procedures are known as "Judet's technique". The aim of this historic review is to outline the genealogy of the orthopaedic arm of the Judet family, while crediting each surgical procedure to the specific family member that described the technique.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines.

BACKGROUND: Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes. METHODS: A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines. RESULTS: Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol. CONCLUSION: Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Modified Bilhaut-Cloquet procedure for Wassel type III-IV polydactyly.

BACKGROUND: To investigate the functional and aesthetic results of a new modified Bilhaut-Cloquet procedure for the treatment of Wassel type III-IV thumb polydactyly. METHODS: Thirteen patients with Wassel type III-IV thumb polydactyly who visited the Department of Orthopedics of Hebei Provincial Children's Hospital from 2019 to 2022 were selected. The surgical procedure involved a modified Bilhaut-Cloquet surgery, where two-thirds of the distal part of the dominant finger was retained as the p body of the reconstructed thumb. The triangular bone block of the ablated distal thumb that did not contain the epiphysis and articular cartilage was sutured and fixed, and the neurovascular flap of the ablated distal thumb was used as an augmenting segment of the reconstructed thumb, with the nail bed and nail matrix exquisitely sutured. The evaluation performed according to the Japanese Society for Surgery of the Hand (JSSH) system. RESULTS: All 13 children showed bone healing, no wound infection, nonunion, or deformity healing. None of the children showed a significant reduction in the active and passive mobility of the thumb postoperatively compared with preoperatively. Postoperative evaluation was performed based on the JSSH score, with a mean of 17.15 points (14-19 points), with 11 children rated as excellent and two as good. No severe nail ridges, nail gaps, or nail split deformities of the thumb were observed postoperatively. Postoperative metacarpophalangeal and interphalangeal joint movements were not reduced compared with preoperative movements. All parents were satisfied with the appearance and function of the reconstructed thumb. CONCLUSION: The modified Bilhaut-Cloquet procedure designed in this study was satisfactory for Wassel type III-IV thumb polydactyly without affecting the stability of the interphalangeal joints and preserving joint mobility. The postoperative thumb has a comparable circumference and nail width and was cosmetically and functionally satisfactory, especially for the asymmetric two thumbs, which achieved favorable results.