Analysis of robot-specific operative time and surgical team anxiety level and its effect on alignment during robot-assisted TKA

Adapting to robotic-assisted (RA) total knee arthroplasty (TKA) is hindered by the surgeon's fear of extra time. The main purpose of this study was to determine the robot's operative time, and the secondary goals were to assess the surgical team's anxiety, implant location and size, and limb alignment. From February to April 2022, 40 participants participated in prospective research. The study included primary Cuvis joint active RA-TKA patients for end-stage arthritis, but conversion of unicompartmental knee arthroplasty to TKA, and patients with prior knee surgery were excluded. The active RA-TKA surgical time included surgeon-dependent and surgeon-independent/active robot time. The surgeon's anxiety was measured using the state-trait anxiety inventory (STAI). The implant size/position and limb alignment were checked by post-operative weight-bearing lateral, anteroposterior, and full-length scanograms. Operative time specifically related to active RA-TKA was higher in the first 10 cases as against 10-20, 20-30 and 30-40 cases which was observed to lower from cohort 2. A similar trend was observed for the surgical team's anxiety levels which seem to lower from cohort 2 (case 10-20). Cumulative experience of active RA-TKA showed no effect on the precision of implant alignment/ size, limb alignment and complications. The study showed progressive improvement in the surgical anxiety scores and reduction in operating time indicating the proficiency gained by the surgical team. Further no learning curve was involved in achieving the implant positioning and sizing, limb alignment with the absence of complications.

Intra-operative Safety of an Autonomous Robotic System for Total Knee Replacement: A Review of 500 Cases in India

Background

Manual total knee arthroplasty (TKA) has been documented several times for their safety and complications data. In contrast, there is a limited evidence-based analysis for safety and complications of autonomous robotic-assisted (RA)-TKA. This study aimed to evaluate the safety features and intra-operative surgical complications associated with the use of Cuvis Joint™ autonomous robotic system for TKA.

Methods

The study included 500 consecutive patients who underwent TKA using the Cuvis Joint™ autonomous robotic system from November 2020 to November 2021. All surgeries were performed by a senior surgeon. Patients in whom the surgery was abandoned midway due to technical errors, were excluded from the analysis. In case of unilateral abandonment of the robotic arm during a bilateral RA-TKA, data of the side on which the surgery was completed with robotic assistance was recorded.

Results

There was no incidence of neurological injury, vascular injury, extensor mechanism disruption, or medial collateral ligament injury. There was one case of superficial abrasion of the patellar tendon; however, it did not require any intervention. There were no cases of midway abandonment due to threatened soft tissue injury. There was no intra-operative pin loosening or stress-related fractures at the pin sites. There was one case of Steinmann pin breakage and another case of drill bit breakage, which were removed without any damage to the bone.

Conclusion

The Cuvis Joint™ autonomous robotic system for TKA is safe with no significant intra-operative complications.

Surgical Technique of Direct Anterior Approach for Primary Total Hip Arthroplasty Using a Leg Positioning Traction System

Introduction

Through the use of a natural intramuscular and internervous interval, the direct anterior approach (DAA) for total hip arthroplasty (THA) has been suggested to have several advantages over other popular arthroplasty approaches. The usage of DAA for THA has considerably grown in the West in recent years due to the emphasis on tissue preservation and minimally invasive joint replacements. However, due to the long learning curve, literature on this approach originating from India has been inadequate, suggesting a limited adoption of this surgical technique by the Indian diaspora of practicing surgeons.

Technical Description

The DAA for THA is reliable and suitable to all conventional primary and revision THA cases. In the surgical procedure, the patient is positioned supine on the standard operating room (OR) table with the legs positioned in the Leg Positioning Traction System. The OR table may rotate, which enables the surgeon to perform the surgery more conveniently as it covers the majority of the patient's center of gravity. The incision is made over the tensor fascia lata. After femoral neck osteotomy, the head is removed, and traction is applied to the operative leg followed by acetabular cup insertion. The femoral stem is inserted after releasing soft tissues around the proximal femur using the leg positioning traction system. Using traction, flexion, and internal rotation, the femoral head is pushed into the acetabulum at the same time, and reduction is achieved.

Conclusion

DAA for THA technique offers patients the advantage of minimally invasive surgery compared to other approaches. Many authors have published their experiences and technical keys to successfully completing this procedure, and several variations of the procedure have been described. The approach described is implemented utilizing specifically developed instruments, including a specialized table and intraoperative fluoroscopy while employing the standard surgical incision. This article attempts to outline the authors' technique for performing the DAA in the supine position for a primary THA using a Leg Positioning Traction System, with a focus on technical details in assisting an early DAA convert in making a safe transition.

Exploring patient acceptability of a short-stay care pathway in hospital post arthroplasty: A theory-informed qualitative study

INTRODUCTION

Arthroplasty is an effective, yet costly, surgical procedure for end-stage osteoarthritis. Shorter stays in hospital are being piloted in Australia. In some countries, short stay is established practice, associated with improving perioperative care and enhanced recovery after surgery practices. Exploring the acceptability to patients of a short stay care pathway in hospital postarthroplasty is important for informing health policy, adoption and potential scalability of this model of care.

METHODS

Consecutive patients at one site, at least 3 months post total joint arthroplasty, were invited to participate in theory-informed semi-structured qualitative interviews. The Theoretical Framework of Acceptability (TFA) informed development of the interview guide. Interview data were analysed using the Framework Method.

RESULTS

Eighteen patients were invited. Fifteen consented to be contacted and were interviewed. Short-stay post arthroplasty was highly acceptable to patients who had the supports necessary to recover safely at home. Key findings were as follows: flexibility of short-stay care pathway was essential and valued; prior beliefs and expectations informed acceptability; and the absence of out-of-pocket expenses had an incentivizing effect, but was not the primary reason for patients choosing this care pathway. Further themes analysed within the TFA constructs highlighted nuances of acceptability relating to this model of care.

CONCLUSIONS

A short stay in hospital post arthroplasty appeared to be acceptable to patients who had experienced this care pathway. Our thematic findings identified aspects of the short-stay care pathway that enhanced acceptability and some aspects that limited acceptability. These findings can inform refinement of the short-stay care pathway.

PATIENT OR PUBLIC CONTRIBUTION

Patients/people with lived experience were not involved in the study design or conduct of this preliminary work; as this short-stay model of care was recently introduced, only a small group of patients was eligible to participate in this study. This study is the first step towards understanding the experiences of patients about a short-stay model of care post arthroplasty. The findings will help inform future patient and public involvement in expanding the programme.

Proximal Hamstring Repair - Surgical Pearls for the Novice

INTRODUCTION

Proximal hamstring injuries are rarely encountered sport injuries which cause great functional impairment in the activities of performance. Since these injuries are rarely encountered in orthopedic training, many young surgeons find it challenging to explore and successfully perform the required repairs. The technical demands of tendon retraction, scar tissue formation along with a great possibility of nerve injury during surgical dissection make these procedures a nightmare for young surgeons.

RESULTS

Between January 2020 and December 2021, 11 patients underwent a proximal hamstring repair at our practice. All cases were of acute hamstring tears and diagnosed on magnetic resonance imaging (MRI) evaluation post-injury. No repeat MRI was performed but the patients outcomes were judged based on clinical outcomes such as return to sport or the presence of residual pain. All patients reached their pre-injury level of activity within 6 months of surgical repair.

CONCLUSION

This technical note describes pearls of surgical repair of these injuries that help in better execution of such injuries with minimal soft tissue damage and complications.

Overnight or Short Stay Joint Replacements in the Public and Private settings: An Australian Experience

Introduction: In today’s post COVID 19 world, many healthcare systems have been pushed past the brink of economic sustainability. With Total Hip (THR) and Knee Replacements (TKR) being a few of the biggest ticket items, the need to adopt methods that improve quality of care & reduce unnecessary costs, is imperative. In this context, we report our experience with a Short Stay / Overnight joint replacement model using an ERAS (Enhanced Recovery After Surgery) Protocol which promotes rapid post-operative recovery and a decreased LOS without an increase in complications or readmission rates.   Method: Retrospective collection of clinical & demographic data was undertaken for 114 consecutive patients undergoing primary THR or TKR by a single surgeon between 1 January 2018 and 19 March 2020 at 2 hospitals (1 public, 1 private). The data was analyzed for LOS, complications & readmission rates within 90 days after surgery.   Results: In THR (n=93) and TKR (n=21), mean LOS was1.54 nights (range 0 - 4). 8 patients were discharged to a rehabilitation facility, the remaining 106 were discharged home. 2 patients were readmitted within 90 days of surgery - one with a periprosthetic fracture and the other for an unrelated respiratory illness.   Conclusion: The implementation of a Short Stay model and associated ERAS protocols in both the public and private hospital settings reduced LOS without a concomitant increase in postoperative complications or readmission rates.

Tuberculosis (T.B.) masquerading as tumor. An 8-year study on 25 cases of long bone tuberculosis presenting as tumors

Aim: To highlight radiological features and emphasize the need for tissue diagnoses to confirm bone pathology. Tuberculosis is known to present without constitutional symptoms and with unconventional imaging features mimicking sarcomas as shown in our series of 25 patients; where the imaging and biopsy protocols at our institute helped to solve these diagnostic dilemmas. Material and methods: We retrospectively analyzed clinical and radiological features and tissue diagnoses in 25 patients referred to the department of orthopedic oncology with radiological suspicion of tumor. Results: Only 7 patients had cultures positive for Mycobacterium Tuberculosis T.B. Radiological features suggestive of infection were Metaphyseal and joint involvement, permeative lesions, absence of Codman’s triangle, and soft tissue mass suggestive of a cold abscess. The predictive accuracy of the orthopedic oncologist was 60% and musculoskeletal radiologist was 72% (based on radiology). Final diagnosis is 100% confirmed on histopathology. Conclusion: Diagnosis based primarily upon imaging is a wrong approach. A multimodal approach to differentiating tuberculous bone infections from sarcomas is essential.

Intra- operative fractures in primary Total Knee Arthroplasty

BACKGROUND

Intraoperative fracture during primary Total Knee Arthroplasty (TKA) is very rare and there is little literature available which has defined the possible reasons for the occurrence of these fractures. Further, no study till date has defined the various management options available to treat these fractures. This study aims to define (1) the possible reasons for different fracture patterns occurring intraoperatively, (2) the ideal management options for each type of fracture geometry, (3) whether this intraoperative complication affects the physiotherapy protocol and long term outcomes.

METHODS

Out of 3168 primary TKA done between 2010 and 2017, 19 patients developed intraoperative fracture, whose data was evaluated retrospectively. Patients were assessed radiologically to determine the time to union and clinical outcomes were assessed using Knee Society Score.

RESULTS

Out of the 19 intraoperative fractures, 19 were in Tibia and 4 in Femur. Majority of fractures occurred during cementing and final implantation (8 cases), followed by exposure and bone preparation (6 cases) and the least during trialing (4 cases). Out of 15 Tibia fracture, 9 fractures involved the Tibial cortex which were managed with screws (4 cases), sutures and bone cement (5 cases). Stemmed tibial component was used for all Plateau type fracture patterns (6 cases). Out of 4 distal femur fractures, condylar type fracture pattern were fixed with plates and screws (3 cases) and epicondyle avulsion with screws alone (1 case). All the cases showed union (average union time 8.9 weeks) and good KSS scores which remained till their last follow-up. None of the patient developed any other complications or required revision surgery.

CONCLUSIONS

Intraoperative fracture during TKA, although rare but a significant complication which can affect the outcome, if not managed properly. We have shown methods of management for such cases, which have given excellent results.

Symptomatic medial humeral epicondylar fracture non-union- rare presentation of a relatively common injury

BACKGROUND

Symptomatic non-union of medial humeral epicondylar fractures is a limited entity. Some studies recommend surgical excision of the fragment, but the results are controversial. The purpose of this study is to evaluate the outcome of open reduction and internal fixation of a medial epicondyle non-union fragment.

MATERIALS AND METHODS

A retrospective study was conducted in all the patients, who were operated in our hospital between the year 2010 and 2015 for symptomatic medial humeral epicondyle non-union. Inclusion criteria were open reduction and internal fixation of symptomatic medial epicondyle non-union and minimum one year of follow-up from time of surgery. Exclusion criteria included other associated musculoskeletal disorders of the affected limb. Open reduction and internal fixation of the fragment was done in all patients and the ulnar nerve was decompressed and anteriorly transposed in cases where symptomatology was present. Outcome was assessed with radiograph, range/arc of motion, Visual analogue pain scoring and two functional outcome tools.

RESULTS

Study sample consisted of 14 patients, with mean age at presentation of 14.9 years (range 6 to 50 years) with mean time since injury of 7.7 months (range 3 to 24 months). Patients presented with medial elbow pain and prominence, limited range of motion, valgus instability, and ulnar nerve compression. After open reduction and internal fixation, at a mean of three years after surgery (range 1.5 to 5 years), patients reported an improvement in visual analogue pain score from a mean of 7.29±1.3 to 0.21±0.4, and the difference was statistically significant (p=0.001). Mean postoperative Quick DASH (Disability of Arm, Shoulder, and Hand) score was 5.21±7.2. Mean Mayo Elbow Performance Score was 96.7±6.1. Improvement in arc of motion was statistically significant (p=0.001). Radiographic union was achieved in all patients except one who had fibrous union. Functional elbow range of motion was achieved in 13 out of 14 cases (92.8%) and ulnar nerve recovered in five patients and one patient required tendon transfer.

CONCLUSION

Open reduction and internal fixation of symptomatic medial humeral epicondyle non-union gives excellent clinical and functional outcome in the majority of cases.

Swallow syncope: reflex or reflux?

A 51-year-old man presented with symptoms of syncope on consuming solid foods. He had a 5 year history of intermittent symptoms on eating only solids and his cardiovascular investigations revealed bradycardia during food ingestion. He was treated by insertion of a pacemaker with cessation of his syncopal symptoms.

Crossed actions on group II-activated interneurones in the midlumbar segments of the cat spinal cord

1. Evidence has been sought for crossed actions on midlumbar propriospinal neurones activated by ipsilateral group II muscle afferents, with particular emphasis on those neurones with projections to the ipsilateral hindlimb motor nuclei. 2. A large majority of group II-activated midlumbar neurones were influenced by stimulation of contralateral group II afferents. The most frequent and most powerful actions were from those nerves which most effectively influenced ipsilateral midlumbar neurones. Crossed actions from group I afferents were rare. 3. In the great majority of neurones the pattern of actions was similar from both limbs, the neurones being bilaterally excited, bilaterally inhibited or had both EPSPs and IPSPs from both sides. 4. The latencies of crossed actions suggest that the earliest crossed EPSPs from group II afferents were evoked disynaptically (i.e. via a single commissural neurone) and that the crossed IPSPs were evoked trisynaptically. 5. The pattern of crossed actions suggests a strong bilateral interaction between midlumbar neurones. The possible role of these neurones in postural control and the production of co-ordinated movements of the hindlimbs is discussed.

Crossed reflex actions from group II muscle afferents in the lumbar spinal cord of the anaesthetized cat

1. The effects of electrical activation of muscle nerves at strengths sufficient to activate group II afferents in contralateral hindlimb motoneurones have been investigated by intracellular recording from motoneurones in alpha-chloralose-anaesthetized cats in which the spinal cord was intact or transected at a low thoracic level. 2. A large proportion of the motoneurones encountered could be influenced by activation of contralateral group II afferents. With the spinal cord intact, the predominant effect of contralateral group II afferents was inhibitory in almost all motoneurones, including extensors. After spinal transection the same stimuli elicited EPSPs in extensor motoneurones and IPSPs in flexors. 3. Both with the spinal cord intact and following spinal transection, group II afferents from particular nerves had powerful effects, whereas others were without effect in most neurones and had weak effects in others. Stimulation of gastrocnemius-soleus or of the hamstring nerves was largely ineffective, evoking weak effects in a small minority of motoneurones. Stimulation of the quadriceps, tibialis anterior-extensor digitorum longus and flexor digitorum longus nerves had powerful effects and in a high proportion of motoneurones. 4. The minimal latencies of the IPSPs evoked prior to spinalization were directly comparable to those of IPSPs evoked from ipsilateral group II afferents. The possibility that the mid-lumbar region, where many neurones which mediate ipsilateral group II reflexes are located, might mediate these crossed effects is discussed.

Patchy intrinsic connections of the ferret primary auditory cortex

Small iontophoretic injections, of the leucoagglutinin extracted from Phaseolus vulgaris (PHA-L), were made at a depth of 600 microns, into the ferret primary auditory cortex (AI). The lectin anterogradely labelled the axons of pyramidal cells located in the upper layers. The axons had collaterals which terminated in 5-8 columns within AI. The columns were 0.25-0.8 mm in diameter and, based on their position, appeared to be in areas of cortex where the cells would have higher and lower as well as equivalent characteristic frequencies to those in the injection site.

Pseudopsychopathic syndrome in hydrocephalus: a case report and review

A 24-year-old man with a head injury developed a communicating hydrocephalus and underwent ventriculoperitoneal shunting. A revision was required, and the patient emerged from coma with severe behavior outbursts, which persisted for more than 1 year. Computed tomographic scans indicated a recurrence of low-pressure communicating hydrocephalus and a shunt revision was performed. The patient's severe behavior outbursts immediately decreased dramatically. The improvement continued long term and extended beyond the acute rehabilitation program.

Transdiaphragmatic migration of a ventriculoperitoneal catheter

A child developed an infected hydrothorax and respiratory distress 3 years after the insertion of a ventriculoperitoneal shunt. The distal catheter had penetrated the right pleural space via retrohepatic transdiaphragmatic migration.

Factors affecting solubilization of the D1 receptor from bovine caudate nucleus

The D1 dopamine receptor was identified using the dopamine agonist 3H-ADTN. The ability of various detergents to solubilize this receptor from bovine caudate nucleus was examined. In order to maintain high affinity binding, receptors were solubilized in the presence of dopamine and manganese. GPP(NH)P reduced the yield of soluble receptors. Of the detergents tested, n-octyl-B-D-glucopyranoside gave the best yield of receptors capable of binding 3H-ADTN and related compounds with high affinity.