Latarjet procedure restores range of motion at six months postoperatively: a prospective cohort study utilizing motion capture analysis.

BACKGROUND: There is a common concern that range of motion (ROM) is negatively affected by the Latarjet procedure. We hypothesize that the Latarjet procedure results in full recuperation of ROM postoperatively and significantly improved patient reported outcome measures. METHODS: Patient data were prospectively collected from a randomized controlled trial to analyze outcomes after open Latarjet procedure. Inclusion criteria involved a minimum follow-up of six months and unilateral shoulder instability. Study outcome was assessed by postoperative ROM at six months postoperatively and compared to the preoperative ROM of the ipsilateral shoulder as well as the ROM of the unaffected contralateral shoulder. All ROM measurements were performed utilizing a motion capture system to ensure consistent and reliable measurements. RESULTS: The study included a total of 84 patients. ROM was measured in external rotation with the shoulder adducted (ER1), external rotation with the shoulder abducted 90 degrees (ER2), internal rotation with the arm abducted 90 degrees (IR2), and active forward elevation (AE). The average difference in ROM between the operated arm vs. the contralateral healthy arm at six months postoperatively was 3.4 degrees in ER1 (p=0.19), 4.2 degrees in ER2 (p=0.086), 2.2 degrees in IR2 (p=0.36), and 2.4 degrees in AE (p=0.045). Sub-analysis of patients with and without sling use revealed no significant difference in ROM between the operated shoulder and contralateral shoulder at six months in either group, with the exception of ER2 in the sling group. In this latter group, ROM was 71 degrees in the operated arm and 79 degrees in the contralateral arm (p=0.0094). Average preoperative pain score was 25.7 (21.4-30.1, 95%CI) vs. 13.0 postoperatively at six months (9.50-16.5, 95%CI) (p <0.00001). Average preoperative SANE instability was 42.9 (38.4-47.3, 95%CI) vs. 86.2 postoperatively at six months (83.6-88.7, 95%CI) (p <0.00001). Average preoperative Rowe score was 38.5 (34.3-42.7, 95%CI) vs. 84.3 at six postoperative months (81.1-87.4, 95%CI) (p<0.00001). CONCLUSIONS: Latarjet procedure performed for anterior instability utilizing a capsular repair result in complete ROM recovery in ER1, ER2, and IR2 at six months postoperatively, with only a slight discrepancy in active elevation. Sling use after the Latarjet procedure results in no benefit over postoperative recovery without the use of a sling. Sling use negatively affects the ROM in ER2, taking as reference the contralateral arm of the same patient, when compared to patients that did not use a sling postoperatively.

A feasibility cadaver study for placing screws in various pelvic osseous fracture pathways using a robotic arm.

INTRODUCTION: The use of a robotic system for the placement of pedicle screws in spine surgeries is well documented in the literature. However, there is only a single report in the United States describing the use of a robotic system to place two screws in osseous fixation pathways (OFPs) commonly used in the treatment of pelvic and acetabular fractures in a simulated bone model. The purpose of this study was to demonstrate the use of a robotic system to place screws in multiple, clinically relevant OFPs in a cadaveric model and to quantitatively measure accuracy of screw placement relative to the preoperative plan. METHODS: A single cadaveric specimen was obtained for the purpose of this study. All surrounding soft tissues were left intact. Screws were placed in OFPs, namely iliosacral (IS), trans-sacral (TS), Lateral Compression-II (LC-II), antegrade anterior column (AC) and antegrade posterior column (PC) of the right hemipelvis using standard, fluoroscopically assisted percutaneous or mini-open technique. Following the placement of screws into the right hemipelvis using standard techniques, screws were planned and placed in the same OFPs of the contralateral hemipelvis using the commercially available ExcelsiusGPS® robotic system (Globus Medical Inc., Audubon, PA). After robotic-assisted screw placement, a post-procedure CT scan was obtained to evaluate actual screw placement against the pre-procedure plan. A custom-made image analysis program was devised to measure screw tip/tail offset and angular offset on axial and sagittal planes. RESULTS: For different OFPs, the mean tip offset, tail offset and angular offsets were 1.6 ± 0.9 mm (Range 0.0-3.6 mm), 1.4 ± 0.4 mm (Range 0.3-2.5 mm) and 1.1 ± 0.4° (Range 0.5-2.1), respectively. CONCLUSION: In this feasibility study, surgeons were able to place screws into the clinically relevant fracture pathways of the pelvis using ExcelsiusGPS® for robotic-assisted surgery. The measured accuracy was encouraging; however, further investigation is needed to demonstrate that robotic-assisted surgery can be used to successfully place the screws in the bony corridors of the pelvis to treat traumatic pelvic injuries.

Glenoid-based reference system to differentiate shoulder pathologies on plain radiographs.

BACKGROUND: Shoulder radiographs are used for evaluation and the planning of treatment of various pathologies. Making a diagnosis of these pathologies on plain radiographs occurs by recognizing the relationship of the humeral head on the registry of the glenoid. Quantification of these changes in registry does not currently exist. We hypothesize that a geometric relationship of the humeral head and the glenoid exists that is defined on an anteroposterior Grashey view radiograph by the relationship of the best-fit circle of the humeral head relative to the best-fit circle of the glenoid such that relative measurements will define the normal shoulder and the pathologic shoulder. METHODS: One hundred fifty-six shoulders were included: 53 normal shoulders, 51 with primary glenohumeral osteoarthritis (GHOA), and 52 with cuff tear arthropathy (CTA). Humeral head best-fit circle was used to define the circle of the humeral head (cHH). A glenoid best-fit circle (cG) was defined by the following rules: (1) best fit of the glenoid articular surface and (2) was limited by the acromion such that either (a) it reaches maximal interaction with the inferior surface of the acromion or (b) the perimeter of the circle is at the lateralmost point of the acromion. The relationship between cHH and cG is defined by measurement of cHH in horizontal and vertical planes relative to the glenoid circle reference. The horizontal displacement angle (HDA) measures the horizontal position of cHH relative to cG, representing the degree of medialization toward the glenoid. The vertical displacement angle (VDA) measures the vertical position of cHH relative to cG, representing the degree of superiorization toward the acromion. Angles were compared by diagnosis and sex. RESULTS: The mean HDA was 61.0° (95% confidence interval [CI] 60.3°-61.7°) in normal shoulders, 79.9° (95% CI 76.9°-82.9°) in GHOA, and 63.4° (95% CI 61.7°-65.1°) in CTA (P < .001). The mean VDA was 43.1° (95% CI 42.2°-44.0°) in normal shoulders, 40.9° (95% CI 39.9°-42.0°) in GHOA, and 59.7° (95% CI 57.6°-61.7°) in CTA (P < .001). Interobserver reliability was 0.991 (95% CI 0.94-1.0) and intraobserver reliability was 0.998 (95% CI 0.99-1.0). The geometric relationship of cHH to the glenoid circle reference was plotted for each group. CONCLUSION: A geometric relationship exists of the humeral head in reference to the glenoid circle. Together, the HDA and the VDA distinguish between a normal shoulder and those with GHOA or CTA. This suggests that this novel methodology may provide a preoperative planning tool that is easily accessible.

Robotic-assisted percutaneous pelvis fixation: A case report.

Key Clinical Message: It may be possible to extend the use of the robotic arm to pelvic and acetabular surgery leading to safe, repeatable screw placement, and less radiation exposure for patients, surgeons and OR staff. Abstract: In this case, a novel, robotic-assisted technique was used to place a sacroiliac screw in a patient with unstable injuries of the pelvic ring. Intraoperative and postoperative fluoroscopic, radiographic, and CT imaging demonstrated a safely positioned 6.5 mm cannulated screw without unplanned cortical violation or impingement on neurovascular structures. To our knowledge, this is the first such reported case using a robot widely available in the Americas or Europe.

Does Preoperative Opioid Consumption Influence Patient Satisfaction following Total Knee Arthroplasty?

Chronic opioid use prior to total knee arthroplasty (TKA) has been implicated in adverse outcomes. The purpose of this study was to evaluate clinical outcome measures and patient satisfaction in patients with a history of preoperative chronic opioid use undergoing primary TKA. A retrospective cohort study was performed on 296 consecutive patients undergoing primary TKA. Seventy-four (25%) patients were identified with chronic preoperative opioid use (study group; 22 males, 52 females). A 3:1 matched cohort ratio of control versus study group was utilized resulting in a control group consisting of 222 patients (97 males, 125 females) without chronic opioid use prior to surgery. There was no statistically significant difference in age, BMI, or follow-up. Average follow-up was 23.4 months in the control group and 23.6 months in the study group (p = 0.87). Clinical data including patient satisfaction (Likert score), Knee Society (KS) Knee scores, KS Function scores, Forgotten Joint Score (FJS), length of stay (LOS), and complications were evaluated. Patient satisfaction at the most recent visit was 92.8% in the control group versus 83.8% in the chronic opioid group (p = 0.0016). Differences in patient-reported outcomes measures comparing the control and study cohorts included KS Function Score of 83.23 versus 75.31 (p = 0.0034). The FJS of 63.7 versus 58 (p = 0.1883) and the KS Knee Score of 89.5 versus 88.1 (p = 0.4075) were not significant. Postoperative opioid usage for the control versus the study group was 62/222 (27.9%) versus 56/74 (75.7%) at 4 to 8 weeks (p <0.0001), and 4/222 (1.80%) versus 27/74 (36.5%) at 12 months (p <0.0001). Overall complication occurrence was 18.9% in the study group versus 11.3% in the control group (p = 0.11). Patients with history of chronic preoperative opioid use had significantly lower patient satisfaction and KS Function scores and increased postoperative opioid usage at 12 months compared with patients without a history of opioid use prior to TKA.

Primary THA Using Thin Polyethylene Liners and Large Femoral Heads: A Minimum 5-Year Follow-Up.

BACKGROUND: Large femoral head sizes are commonly used in total hip arthroplasty (THA) to minimize the risk of instability. With small acetabular cup-size, large femoral head diameter often results in the use of thin polyethylene liners. The purpose of this study was to evaluate clinical and radiographic results of large femoral heads against thin polyethylene liners with minimum 5-year follow-up. METHODS: This was a retrospective review identifying 58 primary THAs utilizing thin polyethylene inserts from one manufacturer (X3 polyethylene, Stryker, Mahwah, NJ) and large femoral heads (36 mm or greater) with minimum 5-year follow-up. A total of 3 patients were deceased and 11 lost to follow-up, leaving 44 patients for review. All patients were female with mean age 65.7 (range 26-85) and mean body mass index (BMI) 29.9 (range 19.6-45.4). Average length of follow-up was 8.5 years (range 5.1-11.3). Outcome measures included survivorship, complications, PROMs and radiographic analysis. RESULTS: There were four revisions: two aseptic loosening, one prosthetic joint infection, and one recurrent dislocation. Average HOOS-Jr, FJS-12, and patient satisfaction using Likert score was 94.3/100, 92.9/100, and 4.69/5.00, respectively, with 94% of patients reporting being satisfied or very satisfied. Radiographic analysis at average of 8.5 years demonstrated well-fixed implants without evidence of progressive radiolucent lines, osteolysis, or failure of the polyethylene liner. Survivorship using failure of the thin polyethylene liner as the endpoint was 100% at an average of 8.5 years. CONCLUSION: Thin polyethylene liners used with large femoral head sizes in small acetabular cups demonstrated excellent results at average 8.5-year follow-up with no cases of liner fracture or osteolysis.

Patient satisfaction following total knee arthroplasty using restricted kinematic alignment.

AIMS: Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment. METHODS: A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019. RESULTS: Mean overall patient satisfaction for the entire cohort was 4.7 (SE 0.1) on a 5-point Likert scale, with 93% being either very satisfied or satisfied compared with a Likert of 4.3 and patient satisfaction of 81% in the mechanical alignment group (p < 0.001 and p < 0.006 respectively). At mean follow-up of 17 months (11 to 27), the mean overall Likert, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and Knee Society Knee and Function Scores were significantly better in the kinematic group than in the neutral mechanical alignment group. The most common complication in both groups was contracture requiring manipulation under anaesthesia, involving seven knees (6.1%) in the kinematic group and nine knees (7.8%) in the mechanical alignment group. CONCLUSION: With the advent of advanced technology, and the ability to obtain accurate bone cuts, the target limb alignment, and soft-tissue balance within millimetres, using a restricted kinematic alignment concept demonstrated excellent patient satisfaction following primary TKA. Longer-term analysis is required as to the durability of this method. Cite this article: Bone Joint J 2021;103-B(6 Supple A):59-66.

Effect of Tourniquet Use on Patient Outcomes After Cementless Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Tourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes. METHODS: Patients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected. RESULTS: Visual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent. CONCLUSION: This study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level.

Improved Patient Satisfaction following Robotic-Assisted Total Knee Arthroplasty.

Approximately 20% of the patients are dissatisfied with their total knee arthroplasty (TKA). Computer technology has been introduced for TKA to provide real time intraoperative information on limb alignment and exact flexion/extension gap measurements. The purpose of this study was to determine if patient satisfaction could be improved with the use of robotic-assisted (RA) technology following primary TKA. A total of 120 consecutive patients undergoing RA-TKA with real time intraoperative alignment and gap balancing information were compared with a prospective cohort of 103 consecutive patients undergoing TKA with manual jig-based instruments during the same time period. There were no differences between groups with age, gender, baseline Knee Society Score (KSS) knee and function scores, follow-up, and ASA scores. TKAs were performed using same technique, implant design, anesthesia, and postoperative treatment protocols. Patient satisfaction survey using KSS and Likert scoring system were obtained at 1-year follow-up. Likert scoring system demonstrated 94% of the patients in the RA group were either very satisfied or satisfied versus 82% in the manual instruments TKA group (p = 0.005). RA-TKA group had better average scores of all five satisfaction questions although not significant. RA-TKA group had a better average overall satisfaction score of 7.1 versus 6.6 in the manual instrument group, p = 0.03. KSS function scores were significantly better at 6 weeks and 1 year postoperatively (p = 0.02, 0.005), and KSS knee scores were significantly better at 1 year postoperatively (p = 0.046). There are multiple reasons for patient dissatisfaction following primary TKA. Using intraoperative computer technology with RA surgery for patients undergoing a primary TKA, a significant improvement in patient satisfaction was demonstrated compared with TKA using conventional manual jig-based instruments. RA surgery provides several advantages in TKA including real time information in millimeters to help obtain balanced gaps, accurate bone cuts, reduced soft tissue injury, and achieve the target alignment which may lead to improved patient satisfaction.

Decreased Opioid Consumption and Length of Stay Using an IPACK and Adductor Canal Nerve Block following Total Knee Arthroplasty.

Peripheral nerve blocks such as a femoral + sciatic block have demonstrated significant pain relief following TKA. However, these nerve blocks have residual motor deficits which prevent immediate postoperative ambulation. The purpose of this study was to compare outcomes in patients undergoing primary TKA with femoral and sciatic (Fem + Sci) motor nerve blocks versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee and adductor canal block (IPACK + ACB) sensory nerve blocks. A total of 100 consecutive patients were reviewed, 50 received Fem + Sci nerve blocks and 50 received IPACK + ACB blocks preoperatively. There were no differences in the two groups with respect to surgical technique, implant type, postoperative pain, and physical therapy protocols. Differences in opioid requirements, length of stay (LOS), distance walked, and common knee scoring systems were analyzed. Among them, 62% IPACK + ACB patients were discharged on postoperative day 1 compared with 14% in the Fem + Sci group (p < 0.0001). The IPACK + ACB patients had a shorter LOS (mean 1.48 days vs. 2.02 days, p < 0.001), ambulated further on postoperative day 0 (mean 21.4 feet vs. 5.3 feet, p < 0.001), and required less narcotics the day after surgery (mean, 15.7 vs. 24.0 morphine equivalents p < 0.0001) and at 2 weeks (mean, 6.2 vs. 9.3 morphine equivalents, p = 0.025). The use of this combination IPACK and ACB demonstrated improved early ambulation with a decrease in opioid use and length of stay compared with a femoral and sciatic motor nerve block in patients undergoing primary TKA.

Coping with compliance during take-off and landing in the diamond dove (Geopelia cuneata).

The natural world is filled with substrates of varying properties that challenge locomotor abilities. Birds appear to transition smoothly from aerial to terrestrial environments during take-offs and landings using substrates that are incredibly variable. It may be challenging to control movement on and off compliant (flexible) substrates such as twigs, yet birds routinely accomplish such tasks. Previous research suggests that birds do not use their legs to harness elastic recoil from perches. Given avian mastery of take-off and landing, we hypothesized that birds instead modulate wing, body and tail movements to effectively use compliant perches. We measured take-off and landing performance of diamond doves (Geopelia cuneata (N = 5) in the laboratory and perch selection in this species in the field (N = 25). Contrary to our hypothesis, doves do not control take-off and landing on compliant perches as effectively as they do on stiff perches. They do not recover elastic energy from the perch, and take-off velocities are thus negatively impacted. Landing velocities remain unchanged, which suggests they may not anticipate the need to compensate for compliance. Legs and wings function as independent units: legs produce lower initial velocities when taking off from a compliant substrate, which negatively impacts later flight velocities. During landing, significant stability problems arise with compliance that are ameliorated by the wings and tail. Collectively, we suggest that the diamond dove maintains a generalized take-off and landing behavior regardless of perch compliance, leading us to conclude that perch compliance represents a challenge for flying birds. Free-living diamond doves avoid the negative impacts of compliance by preferentially selecting perches of larger diameter, which tend to be stiffer.