With the growing emphasis on the cost of medical care, there is renewed interest in the productivity and efficiency of surgical procedures. We have developed a method to systematically examine the efficiency of the surgical team during primary total knee replacement (TKR). In this report, we present data derived from a series of procedures performed by different joint surgeons. This data demonstrates a variation between the duration and efficiency of each step in this procedure and its relationship to the experience and coordination of the surgeon working with the scrub team. After consent was achieved, videotaped recordings were prepared of ten primary TKR procedures performed by five highly experienced joint surgeons. For quantitative analysis, each procedure was divided into 7 principal tasks from initial incision to wound closure. In order to quantify efficiency, we recorded the occurrence of events leading to delays in each step of the procedure (Table 1). Starting with a total score of 100 points, deductions were made, based on the number of delaying events and its impact on the efficiency of the procedure. A final score for the surgery was then determined using the individual scores from each principal task. The experience of each member of the surgical team in participating in TKR, and in working with the surgeon, were recorded and correlated with the total efficiency score for the entire procedure.Introduction:
Methods:
The diagnosis of periprosthetic joint infection (PJI) remains a serious challenge. Based on previous work, we believe that biomarkers will become the mainstay of diagnosing PJI in the future. We report on completion of our 8 year comprehensive biomarker program, evaluating the diagnostic profile of the 15 most promising synovial fluid biomarkers. Synovial fluid was prospectively collected from 99 patients being evaluated for infection in the setting of revision hip or knee arthroplasty. All synovial fluid samples were tested by immunoassay for 15 putative biomarkers that were developed and optimized specifically for use in synovial fluid. Sensitivity, specificity and receiver operating Characteristic (ROC) curve analysis were performed for all biomarkers.INTRODUCTION:
METHODS:
With the growing emphasis on the cost of medical care, there is renewed interest in the productivity and efficiency of surgical procedures. We have developed a method to systematically examine the efficiency of the surgical team during primary total knee replacement (TKR). In this report, we present data derived from a series of procedures performed by different joint surgeons. This data demonstrates a variation between the duration and efficiency of each step in this procedure and its relationship to the experience and coordination of the surgeon working with the scrub team. After consent was achieved, videotaped recordings were prepared of ten primary TKR procedures performed by five highly experienced joint surgeons. For quantitative analysis, each procedure was divided into 7 principal tasks from initial incision to wound closure. In order to quantify efficiency, we recorded the occurrence of events leading to delays in each step of the procedure. Starting with a total score of 100 points, deductions were made, based on the number of delaying events and its impact on the efficiency of the procedure. A final score for the surgery was then determined using the individual scores from each principal task. The experience of each member of the surgical team in participating in TKR, and in working with the surgeon, were recorded and correlated with the total efficiency score for the entire procedure.Introduction
Methods
Following successful total knee arthroplasty, tibial periprosthetic fractures are rare and patellar fractures are sufficiently dependent upon vascular issues that they constitute a somewhat separate topic. Femoral periprosthetic fractures are extremely difficult to manage, usually producing flexion, internal rotation, and varus deformities. Malunion from insufficient stabilisation and stiffness from excessive immobilisation are the polar perils to be avoided. A variety of conservative treatment options will be discussed, ranging from casting and traction to open reduction and internal fixation. Within the latter category, recent enthusiasm has swayed the pendulum of therapeutic options towards intramedullary fixation. This can be accomplished using Rush rods, interprosthetic and intramedullary rods with fixation screws, and revisional knee arthroplasty techniques with large intramedullary stems. As a general rule, the more aggressive techniques provide the better results, although the severe technical difficulties of managing the osteopenic femoral medullary bone require special techniques and skills. Nonetheless, optimal results producing less than 5° of angulation and over 100° of motion are to be expected.
The current growing enthusiasm for unicompartmental and “minimally invasive” arthroplasties is in no small part predicated on the appeal of a mini-incision. While the quest for ever less intrusive surgical procedures is certainly laudable, the appropriate focus should be more on the quality of the procedure and its results, than on cosmetics and recuperative time. The marketing appeal of a “mini-incision” is undeniable, although it is often used as a “bait and switch” technique for attracting surgical candidates. It is undeniable that expense, pain, and time out of work may be less with these procedures. On the other hand, performing an arthroplasty through a minimal incision increases the complexity and difficulty for surgeons, a reality, which is usually inversely proportional to the quality of the result. Our societal quest for speed may divert our attention from the fact that these are temporising procedures at best, whose longterm success in the general marketplace is completely unknown and which may suffer the fate of other such minimally invasive techniques as interpositional skids, viscosupplementation, and abrasion chondroplasty. The extremely high and long lasting success rates of conventional total knee arthroplasty are difficult to approach, and we are indeed sending a mixed message to our patients when we attempt to sell lesser technologies based on small scars. As we all know, size does matter!
As defined by body mass index (body weight in kilograms divided by height in meters squared) one out of three Americans is “overweight”. The excuses and reasons for this situation are genetic, dietary, cultural, and physiologic – occasionally related to the severity of arthritis, which precludes normal activity. Scandinavian literature has shown a higher incidence of gonarthrosis in obese patients as well as some indication of decremental surgical results. Patient selection requires identification of the distribution of the obesity and its implications for knee surgery. Anaesthetic techniques should stress regional approaches, oxygenation, and modified postoperative regimens. Surgical incisions should be midline, longer than normal, and involve eversion of the patella within its fat envelope. Increased tourniquet length as well as width is mandatory. Wound complications are certainly more common, while the overall statistics from knee arthroplasty in the obese are not discouraging. Greater pressure is placed on the surgeon to achieve perfect alignment and balance, less the patient’s weight unmask the imperfections of the arthroplasty. Sadly, only 18% of people lose weight after joint replacement.