Daniel P. Fick

Acute Paraspinal Compartment Syndrome. A Case Report

Acute compartment syndrome is the condition of raised pressure within an enclosed compartment, such that the perfusion and the function of the tissues within are compromised, resulting in ischemia and eventually necrosis. Although, in theory, it can occur in any compartment, it is most commonly seen in the lower limb. We describe a rare case of acute compartment syndrome in the paraspinal muscles that responded well to surgical decompression. Our patient was informed that data concerning this case would be submitted for publication. Athirty-five-year-old man on the third day of a skiing holiday presented to the emergency department because of severe, unrelenting pain in the right lumbosacral paraspinal area, radiating across the abdomen to the groin. The pain had been present for four hours and had begun spontaneously with no history of trauma. In retrospect, the patient had experienced similar but milder pains during previous ski trips and during long-distance running. There was associated numbness in the right lumbosacral area. Positive findings on physical examination were bilateral paraspinal muscle rigidity associated with swelling, marked tenderness, and loss of the lumbar lordosis. There was dense loss of sensation in the paraspinal area to the midaxillary line and altered sensation extending anteriorly to the midline. Reduced abdominal muscle tone on the right side, resulting in asymmetry, was also noted. Active movement of the spine was minimal and exacerbated the pain. The patient had mild tenderness of the abdomen with absent bowel sounds. The initial differential diagnosis included a renal stone, a herniated disc, discitis, and a retroperitoneal abnormality. A urine specimen was dark in appearance, and analysis revealed 3+ myoglobinuria. Blood chemistry studies showed elevation of aspartate aminotransferase (804 IU/L; …

Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature

BACKGROUND Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. METHODS Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. RESULTS This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. CONCLUSION Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them.

MRI and clinical analysis of hip abductor repair

Introduction Hip abductor insufficiency is often associated with lateral hip pain, movement disorder and Trendelenburg gait. The aims of this study are to predict if preoperative radiological findings correlate with postoperative outcomes and if pre and postoperative radiological findings correlate with postoperative function. Methods Patients with clinical and MRI evidence of hip abductor tears that had failed to nonoperative treatment underwent surgical repair. Pre and postoperative MRI analysis was carried out by an experienced musculo-skeletal radiologist. Clinical analysis consisted of Harris Hip Score, a measure of patient satisfaction, pre and postoperative walking aids and Trendelenburg test. Results This study shows no real improvement in the MRI appearances of the tendons after surgery. Preoperative MRI absence of gluteus minimus was 100% predictive of a poor outcome, whilst thickening of the posterior gluteus medius was 83% predictive of a poor outcome. Postoperative MRI absence of posterior gluteus medius was 75% predictive of a poor outcome. Thickening of anterior gluteus medius and posterior gluteus medius were 71% and 83% predictive of a poor outcome respectively. Absence of posterior gluteus medius correlated with poor outcome in 75% of cases. Discussion The MRI appearance of the tendon does not normalise after surgery and there is limited correlation between the MRI appearances pre and postoperatively with the postoperative outcome.

A review of the physiological and histological effects of laser osteotomy.

Abstract Osteotomy is the surgical cutting of bone. Some obstacles to laser osteotomy have been melting, carbonisation and subsequent delayed healing. New cooled scanning techniques have resulted in effective bone cuts without the strong thermal side effects, which were observed by inappropriate irradiation techniques with continuous wave and long pulsed lasers. With these new techniques, osteotomy gaps histologically healed with new bone formation without any noticeable or minimum thermal damage. No significant cellular differences in bone healing between laser and mechanical osteotomies were noticed. Some studies even suggest that the healing rate may be enhanced following laser osteotomy compared to conventional mechanical osteotomy. Additional research is necessary to evaluate different laser types with appropriate laser setting variables to increase ablation rates, with control of depth, change in bone type and damage to adjacent soft tissue. Laser osteotomy has the potential to become incorporated into the armamentarium of bone surgery.

Tibial Tubercle Osteotomy in Revision Knee Arthroplasty

BACKGROUND Obtaining adequate exposure while maintaining the integrity of the extensor mechanism is crucial to the success of revision knee arthroplasty. This is particularly important in infected cases where staged procedures are necessary. While the use of a long, tibial tubercle osteotomy (TTO) is an established method to improve exposure, controversy still exists concerning complication rates and sequential use. METHODS Forty-two TTOs were performed in revision knee arthroplasties between 2009 and 2015. Follow-up period ranged from 3 to 24 months. Twenty-four TTOs were performed for single-stage revisions, and 18 TTOs were performed for 2-stage infected revisions. In infected cases, the initial osteotomy was left unfixed between stages. Screws were used to fix the osteotomy flap in all cases. RESULTS All osteotomies united with no fractures, and there were no extensor lags. Minor proximal migration was noted in 1 case, and refixation was required in another. Greater range of motion (ROM) and improved Oxford Knee Scores were achieved in the single-stage revision group. In the infected 2-stage group, sequential use did not decrease union rates, and infection was eradicated in 14 of the 16 knees (88%). CONCLUSION We conclude that TTO is a safe and reproducible procedure when exposure needs improving in revision knee arthroplasty. In 2-stage revisions, sequential osteotomies do not decrease union rates, and leaving the osteotomy unfixed after the first stage does not cause any adverse issues.

Patella resurfacing in total knee arthroplasty

This is the protocol for a review and there is no abstract. The objectives are as follows: To identify and summarise the evidence from randomised controlled trials assessing the clinical efficacy and safety of resurfacing the patella versus not resurfacing the patella in total knee arthroplasty. The following null hypotheses will be tested: 1.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with osteoarthritis of the knee. 2.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with inflammatory arthritis of the knee. 3.There is no difference in outcome between not resurfacing the patella and resurfacing the patella with different prosthetic designs. 4.There is no difference in outcome between resurfacing the patella and not resurfacing the patella in patients with grade varying grades of patellofemoral arthritis, and varus or valgus deformity of the knee

The effect of Virtual Reality in reducing preoperative anxiety in patients prior to arthroscopic knee surgery: A randomised controlled trial

Preoperative anxiety positively correlates with postoperative levels of pain, analgesic use and length of hospital stay. This preliminary study aimed to determine if the principle of distraction, using a relaxing Virtual Reality (VR) immersion, would reduce preoperative anxiety in patients undergoing arthroscopic knee surgery. Sixty patients were randomised into three groups (Standard care group, Virtual Reality group and iPad group). Anxiety scores (Hospital Anxiety and Depression Scale), Galvanic Skin Response (GSR), heart rate and blood pressure were measured pre and post intervention. The Standard care group received no intervention. The iPad group watched a video slideshow of beaches around the world and the VR group experienced a virtual beach immersion. Guided relaxation audio content (via headphones) was replicated across VR and iPad groups. Planned comparisons showed a significant difference between the average GSR measures at Time 1 and Time 2 between the Standard group and VR group. GSR measures for the Standard care group increased by 54 per cent from time 1 to time 2 and the VR and iPad groups reduced slightly, demonstrating an ameliorating effect on anxiety levels. A marginal difference between the Standard care group and VR group in anxiety change scores was reported. Whilst the VR condition reduced anxiety more than Standard care in both GSR and Anxiety change score measures, it provided no significant advantage over iPad condition. In conclusion, distraction using VR and iPad temporarily reduces self-reported anxiety levels and GSR measures compared to standard care in patients prior to knee arthroscopy. Further study is required to determine how long-lasting these benefits are in a clinical setting. The continuing advancements in VR technology, including immersion quality, present an opportunity to investigate the application of VR as a ‘digital pre-med’.

Through the eye of the master: The use of Virtual Reality in the teaching of surgical hand preparation

Virtual Reality (VR) demonstrates unique educational benefits over other teaching mediums including enhanced engagement and learner motivation. Such benefits could be exploited to improve teaching of surgical hand preparation (SHP), a practice crucial in preventing post-surgical infection. This study hypothesises that the utilisation of VR technology to demonstrate SHP technique will produce superior skill acquisition and longer skill retention than the standard practice of video demonstration. 40 healthcare students unfamiliar with SHP were recruited from a tertiary university and randomised into two groups. The control group (n=21) viewed a video demonstration of SHP while the VR group (n=19) viewed a VR demonstration of the same technique. Participants were assessed immediately after demonstration (acquisition score), and again one week later (retention score), using a 20-point assessment scale. Scores were compared between the groups. Groups were equal in age, prior education, handedness and gender distribution. Neither skill acquisition (Control mean: 12.29, VR mean: 12.84; p = 0.57) nor retention (Control mean: 12.29, VR mean: 12.74; p = 0.52) differed significantly between groups however a non-significant trend toward better performance in the VR group was observed. Parallel scoring of 35% of participants showed very high inter-rater reliability (intra-class correlation coefficient = 0.92). Utilisation of VR technology did not demonstrate a perceivable acquisition or retention benefit in the teaching of SHP. Future studies could investigate the value of more immersive features including 360-degree point of view or haptic feedback which were not features of the technology used in the present study.

Human joint tissue identification by employing diffuse reflectance and auto-fluorescence spectroscopy, in combination with machine learning

Using optical spectroscopy, we are developing a tissue identification technology for a robotic orthopedic surgery system. Biological tissues are heterogeneous structures that interact with light to absorb, reflect, scatter and re-emit. Reflected light can be measured by diffuse reflectance spectroscopy (DRS) and autofluorescence light can be measured by fluorescence excitation spectroscopy [1]. The majority of biological tissues exhibit unique spectral characteristics in the ultraviolet, visible and near infrared due to their biochemical and morphological state [2, 3]. Therefore, these sensing techniques have been found to be useful for tissue identification. To our knowledge there has been no published research that has explored these modalities to identify the different human joint tissue.

A new technique in revision hip arthroplasty for vancouver B periprosthetic fractures

We describe a new revision technique for Vancouver B periprosthetic hip fractures that leaves the original acetabular components in situ and causes minimal damage to the hip capsule. Twenty-eight patients, average age 79, with Vancouver B periprosthetic fracture had femoral component revision using a modified trochanteric osteotomy with a minimal superior hip capsulotomy. A modular uncemented stem was used with or without cortical strut allograft. The acetabular component was not revised. Fractures occurred in 19 cemented implants and 9 uncemented implants. There were no dislocations. Seventeen patients were available for follow-up at 24 months (range, 3 to 60 mo), average Oxford hip score was 32.2; and Harris hip score 69.7. This new technique has shown good results. We believe that the absence of dislocation in this series is largely attributable to minimal capsular dissection.