RESUMEN
As an alternative to a limited vendor/volume discount approach, our hospital employed a physician-driven free market strategy aimed at reducing joint implant costs. Surgeons were provided with vendor pricing and peer profile comparisons of implant cost data and asked to select implants providing the best value based on patient need. Vendors were challenged to reduce prices where appropriate. Total savings based on the 1995-1997 volume-adjusted cost difference were $1,059,159, a 17.5% decrease. These results demonstrate the possibility of reducing joint implant costs using a strategy that does not limit vendors or cap prices.
Asunto(s)
Competencia Económica , Prótesis Articulares/economía , Artroplastia de Reemplazo/economía , Control de Costos , Ortopedia , Estados UnidosRESUMEN
The ROBODOC system was designed to address potential human errors in performing cementless total hip replacement. The system consists of a preoperative planning computer workstation (called ORTHODOC) and a five-axis robotic arm with a high speed milling device as an end effector. The combined experience of the United States Food and Drug Administration multicenter trial and the German postmarket use of the system are reported. The United States study is controlled and randomized with 136 hip replacements performed at three centers (65 ROBODOC and 62 control). Followup was 1 year on 127 hip replacements and 2 years on 93 hip replacements. No differences were found in the Harris hip scores or the Short Form Health Survey outcomes questionnaire. Length of stay also was not different, but the surgical time and blood loss were greater in the ROBODOC group. This was attributed to a learning curve at each center. Radiographs were evaluated by an independent bone radiologist and showed statistically better fit and positioning of the femoral component in the ROBODOC group. Complications were not different, except for three cases of intraoperative femoral fracture in the control group and none in the ROBODOC group. The German study reports on 858 patients, 42 with bilateral hip replacements and this includes 30 revision cases for a total of 900 hip replacements. The Harris hip score rose from 43.7 to 91.5. In these cases the surgical time declined quickly from 240 minutes for the first case to 90 minutes. No intraoperative femoral fractures occurred in 900 cases. Other complications were comparable with total hip replacements performed using conventional techniques. The ROBODOC system is thought to be safe and effective in producing radiographically superior implant fit and positioning while eliminating femoral fractures.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Robótica , Terapia Asistida por Computador , Adolescente , Adulto , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/instrumentación , Artroplastia de Reemplazo de Cadera/métodos , Pérdida de Sangre Quirúrgica , Sistemas de Computación , Diseño Asistido por Computadora , Femenino , Fracturas del Fémur/etiología , Estudios de Seguimiento , Alemania , Articulación de la Cadera/diagnóstico por imagen , Humanos , Complicaciones Intraoperatorias , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Planificación de Atención al Paciente , Vigilancia de Productos Comercializados , Radiografía , Ensayos Clínicos Controlados Aleatorios como Asunto , Reoperación , Robótica/instrumentación , Robótica/métodos , Terapia Asistida por Computador/instrumentación , Terapia Asistida por Computador/métodos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , United States Food and Drug AdministrationRESUMEN
The number of patients requiring revision total hip arthroplasty continues to increase each year. Accurate preoperative planning is a key factor in obtaining a good result. Radiographs provide little information concerning the actual extent of the acetabular defects. Computed tomography-generated models of the acetabulum can provide the surgeon with accurate information concerning the size and location of the defects. Evaluation of radiographs and models in 24 cases showed that radiographs alone failed to detect all 13 anterior wall defects (P < .001), 8 of 18 posterior wall defects (44.4%, P < .001), and 8 of 19 segmental central defects (42%, P < .001), all of which were easily identified with the models. This study showed that preoperative planning based on the foam models accurately predicted the actual implant used in 22 of 24 cases (92%).
Asunto(s)
Acetábulo/diagnóstico por imagen , Prótesis de Cadera , Procesamiento de Imagen Asistido por Computador , Adulto , Anciano , Anciano de 80 o más Años , Simulación por Computador , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Tomografía Computarizada por Rayos XRESUMEN
Bony abnormalities of the femur can significantly complicate total hip arthroplasty both for the primary and revision operations. No standard nomenclature exists for the description of these femoral abnormalities. A classification system is presented to standardize nomenclature, assist in preoperative planning, and to assist in the reporting of these defects.
Asunto(s)
Fémur/anomalías , Prótesis de Cadera , Desviación Ósea/clasificación , Anomalías Congénitas/clasificación , Fracturas del Fémur/clasificación , Fracturas Mal Unidas/clasificación , Fracturas no Consolidadas/clasificación , Humanos , Planificación de Atención al PacienteRESUMEN
Forty-seven consecutive revision total hip arthroplasties were performed using porous ingrowth custom-made prostheses designed from plain radiographs and computed tomography scans. At an average follow-up period of 30 months (range, 2-4 years), one revision has been required for loosening. The average Harris pain score was 39 and the average total score was 84 at the last follow-up evaluation. Complications included nine cases (19%) with intraoperatively detected fractures of the proximal femur treated with cerclage wires and seven cases (15%) with subsidence greater than 3 mm. There were no postoperative infections and only two dislocations. At the time of surgery local particulate bone graft was used in all cases. Thirty-four percent required structural graft to restore bone stock; no case required grafting for prosthesis stability. Management of bone loss in total hip arthroplasty using a custom cementless prosthesis appears to provide an attractive alternative to massive bone grafting.
Asunto(s)
Resorción Ósea/etiología , Prótesis de Cadera , Adulto , Anciano , Anciano de 80 o más Años , Resorción Ósea/diagnóstico por imagen , Resorción Ósea/cirugía , Trasplante Óseo , Cementación , Femenino , Fémur/diagnóstico por imagen , Fémur/cirugía , Articulación de la Cadera/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Diseño de Prótesis , Radiografía , ReoperaciónRESUMEN
Computer-driven robots and medical imaging technology may soon enable surgeons to plan and execute intricate procedures with unprecedented precision. Our experience in introducing a robotic system for use in an active role in cementless total hip replacement surgery has convinced us that the marriage of these two technologies-robotics and medical imaging-is likely to change the way many types of surgical procedures are performed. The ability to link an image-based preoperative plan with its surgical execution by a robot may be the key to improved outcomes. Research and development of robotic systems for a wide variety of medical applications is underway at a number of prestigious institutions. Grenoble University has developed the IGOR (Imaged Guided Operating Robot) system. This six-axis robot has performed more than 400 interventions, acting as a positioner for brain surgery in both biopsy and therapeutic procedures. AlephMed and Digital are currently assisting the developers in integrating image analysis into the system. Future development plans include an application for spinal surgery.
RESUMEN
The long-term success of cementless total hip arthroplasty (THA) may depend on bone ingrowth into the porous-fixation surfaces of the implant. The ingrowth process is facilitated when the surgeon achieves a satisfactory fit for the prosthesis. Clinically or roentgenographically visible failure and persistent thigh pain after cementless THA remain significant problems, both of which may be alleviated by more precise preparation of the femoral canal and selection of an appropriately sized prosthesis. The objective of this study was to obtain an exact fit for the prosthesis through the use of an image-directed surgical robot for femoral canal preparation.
Asunto(s)
Artroplastia/instrumentación , Prótesis de Cadera , Robótica , Diseño Asistido por Computadora , Articulación de la Cadera/fisiología , Humanos , Oseointegración , Diseño de PrótesisRESUMEN
Most authors agree that "fit" and "fill" of the endosteal canal is critical to the success of cementless femoral components. Yet, there exists a wide variation to the anatomic size and shape of this canal in the normal population. This paper reviews the rationale and the efficacy of using a computed tomography-generated CAD/CAM custom femoral component in cementless total hip arthroplasty. One hundred fifty-six cases (81 primary and 75 revisions) were reviewed with follow-up time of six weeks to three years (mean, 22 months). A subset of 48 hips (25 primary and 23 revisions) has been followed a minimum of two years. For the primary hips, the custom group was found to have statistically higher Harris pain scores (less pain) at all follow-up intervals as compared to a prior series by the same surgeon using an off-the-shelf (OTS) prosthesis. Revision customized hip implants had lower Harris pain and total scores than primary custom hips, but 80% were in the none or slight pain category. In revision cases, the use of custom components decreased the need for structural bone grafting and achieved stability on host bone in situations in which it was not possible using OTS components. Complications included failure by aseptic loosening of one primary and one revision case. Initial subsidence of more than 3 mm of the collarless custom design occurred in 8%, the majority being in revision cases. All cases but one appear to have stabilized. Subsidence occurred mainly in cases done early in the series.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Prótesis de Cadera , Diseño de Prótesis , Inteligencia Artificial , Ingeniería Biomédica , Cementos para Huesos , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Dolor , Falla de Prótesis , Reoperación , Tomografía Computarizada por Rayos XRESUMEN
Total hip arthroplasty, for both primary and revision operations, frequently involves bony abnormalities of the acetabulum. No standard nomenclature currently exists for the definition of acetabular deficiencies. A classification system is presented to assist in the preoperative evaluation and to provide a treatment protocol for these defects.
Asunto(s)
Acetábulo/cirugía , Prótesis de Cadera , Acetábulo/diagnóstico por imagen , Adulto , Enfermedades Óseas/clasificación , Enfermedades Óseas/diagnóstico por imagen , Enfermedades Óseas/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , RadiografíaRESUMEN
The cases of 175 consecutive patients who had intraoperative autologous transfusion during revision total hip arthroplasty, an elective operation on the spine, repair of trauma to the spine, or open reduction of a fracture of the acetabulum were reviewed to evaluate the applicability of this technique in orthopaedic operations. A separate group of forty-one consecutive patients who had open reduction of a fracture of the acetabulum or the spine before the introduction of the autotransfuser was reviewed and compared with the group that had autotransfusion. An autologous blood predeposit program was used for twenty-five of fifty-two patients who had a procedure on the hip and for fifty-one of fifty-five patients who had an elective procedure on the spine. The mean rate of red blood-cell salvage using the autotransfuser was 60 per cent over-all. The mean transfusion requirements were significantly less (p less than 0.001) in all groups of patients in whom the autotransfuser was used. Use of the autotransfuser reduced the mean requirement for banked blood in patients who had a fracture of the acetabulum from 3.8 to 2.3 units per patient, and significantly reduced the mean need for banked blood in individuals who had trauma to the spine from 2.7 to 1.8 units per patient (p less than 0.01). The use of prebanked autologous blood further reduced the mean requirement for homologous blood from 2.4 to 0.8 unit per patient in those who had revision total hip arthroplasty (p less than 0.005), and from 3.6 to 0.4 unit per patient in those who had an elective procedure on the spine (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Transfusión de Sangre Autóloga , Transfusión de Eritrocitos , Articulación de la Cadera/cirugía , Columna Vertebral/cirugía , Transfusión Sanguínea , Transfusión de Sangre Autóloga/métodos , Femenino , Hemorragia , Humanos , Periodo Intraoperatorio , Masculino , Estudios RetrospectivosRESUMEN
The effect of systemic deficiency of estrogen on the growth of tissue into porous titanium-fiber implants was studied in ovariectomized Beagle dogs. Five dogs were ovariectomized and five dogs had a sham operation. After waiting four months to allow the levels of circulating estrogen to decline, a titanium-alloy implant that contained four surface pads of titanium-alloy mesh was implanted in the proximal part of the humerus of each dog bilaterally. Two months later, the implants were harvested and subjected to a mechanical push-out test and quantitative histological study. The push-out strength of the implants from the ovariectomized dogs was 31 per cent less than in the control animals. Ovariectomy caused no difference in the amount of ingrowth of bone but resulted in a significant increase in the amount of fibrous connective tissue within the porous pads. The presence of this fibrous tissue appeared to have an important effect on bone-implant fixation: in the control dogs, strength correlated positively with ingrowth of bone and negatively with ingrowth of fibrous tissue, whereas in the ovariectomized dogs, strength correlated positively with ingrowth of fibrous tissue and not at all with ingrowth of bone.
Asunto(s)
Desarrollo Óseo , Estrógenos/deficiencia , Prótesis e Implantes , Animales , Tejido Conectivo/fisiología , Femenino , Ovariectomía , Ratas , Mallas QuirúrgicasAsunto(s)
Computadores , Prótesis de Cadera , Diseño de Prótesis , Estudios de Evaluación como Asunto , Humanos , TecnologíaRESUMEN
The pull-out strength of two types of bone staples (A, Techmedica; B, Richards) was evaluated in a canine model and compared with a control of 6.5 mm cancellous bone screw (Synthes). Fifteen adult mongrel dogs were divided into three groups of five animals each. The implants were placed in the lateral femoral condyle and proximal humerus on the right side at time zero, and on the left side 3 weeks later. The dogs were killed at 6 weeks. In addition a third site, the tibial tubercle, was used to examine the effectiveness of each device for patellar tendon reattachment. The strength of the reattached patellar tendon was measured and compared with a control intact patellar tendon insertion. The pull-out loads from bone of the two staple types are not statistically different. The displacement to failure, however, was found to be 71% greater (p less than 0.007), and the work to failure 128% greater (p less than 0.010) for staple A as compared with staple B. This may be of clinical relevance in avoiding staple back-out. Both staples were inferior to the screw for pull-out load displacement and work to failure (p less than 0.0001). All reattached tendons were significantly weaker (mean 202 N) than the intact tendon (mean 1,448 N) regardless of implant type. The dissected specimens uniformly showed necrosis of the tendon under the implant. Healing was by massive scar formation surrounding the implant.
Asunto(s)
Dispositivos de Fijación Ortopédica , Animales , Fenómenos Biomecánicos , Tornillos Óseos/efectos adversos , Modelos Animales de Enfermedad , Perros , Fémur , Húmero , Necrosis , Dispositivos de Fijación Ortopédica/efectos adversos , Traumatismos de los Tendones/cirugía , Tendones/patología , TibiaRESUMEN
Histologic changes in the acetabuli of adult dogs were studied following total hip replacement with current cementing techniques. Active bone remodeling was evident throughout the acetabulum by 2 weeks after operation and continued throughout the 6 months of the study, leading to considerable hypertrophy of the trabecular bone of the acetabulum. By 6 months after operation, a thick (average, 0.4 mm), fibrous membrane had formed at the bone-cement interface in 83 of 84 sections examined. Direct apposition of bone to cement was seen only within the 2-mm fixation holes. Formation of a fibrous membrane appears to be intrinsic to the cementing of the acetabular component, perhaps because geometry of the acetabulum precludes effective pressurization of the cement.
Asunto(s)
Acetábulo/patología , Cementos para Huesos/administración & dosificación , Prótesis de Cadera , Animales , Perros , Diseño de Prótesis , Falla de Prótesis , Cicatrización de Heridas/efectos de los fármacosRESUMEN
A canine model was developed to investigate the use of an autogeneic iliac bone graft to treat the calcar deficiency commonly found at the time of revision surgery for femoral component loosening. Five large male mixed-breed dogs had bilateral total hip arthroplasty staged at three-month intervals, and were sacrificed at six months. Prior to cementing the femoral component, an experimental calcar defect was made, and a bicortical iliac bone graft was fashioned to fill the defect. Serial roentgenograms showed the grafts had united with no resorption. Technetium-99 bone scans showed more uptake at three months than at six months in the graft region. Disulfine blue injection indicated all grafts were perfused at both three and six months. Thin section histology, fluorochromes, and microradiographs confirmed graft viability in all dogs. Semiquantitative grading of the fluorochromes indicated new bone deposition in 20%-50% of each graft at three months and 50%-80% at six months. Although the calcar bone graft was uniformly successful in this canine study, the clinical application of this technique should be evaluated by long-term results in humans.
Asunto(s)
Trasplante Óseo , Fémur/cirugía , Prótesis de Cadera , Animales , Desarrollo Óseo , Resorción Ósea , Modelos Animales de Enfermedad , Perros , Fémur/diagnóstico por imagen , Colorantes Fluorescentes , Humanos , Ilion/trasplante , Masculino , Microrradiografía , Cintigrafía , Tecnecio , Trasplante AutólogoRESUMEN
Histologic changes in the femurs of adult dogs were studied following total hip replacement using current cementing techniques. In the diaphyseal region, remodeling was initiated in the periosteum and progressed centripetally over 3 months. In the proximal (metaphyseal) region, remodeling was seen throughout the section by the second week. No fibrous membrane was formed at the bone-cement interface in the proximal region, and only isolated, non-progressive patches of fibrous membrane were formed in the distal region of the implant. The authors attribute the absence of membrane formation to careful preparation of the cement bed and use of pressurized cement injection. The exact congruence of vascularization and remodeling indicates a vascular etiology for the reaction of bone to cemented implantation. Vascular compromise at the time of operation leads to bone necrosis in the affected regions, and subsequent revascularization is a necessary precursor to bone remodeling. Thermal effects and monomer toxicity are considered unimportant.
Asunto(s)
Cementos para Huesos , Fémur/patología , Prótesis de Cadera , Animales , Desarrollo Óseo , Regeneración Ósea , Perros , Cicatrización de HeridasRESUMEN
Samples of polymethylmethacrylate (PMMA) bone cement were polymerized in vitro with no additives and with the following additives: methylene blue dye, tobramycin, methylene blue plus tobramycin. After storage for 7 days in saline, samples were tested to failure in three-point bending. Addition of the antibiotic significantly weakened the cement (to 87% of control). However, the combination of tobramycin plus methylene blue was no weaker than tobramycin alone, suggesting that addition of both dye and antibiotic to bone cement is probably a reasonable clinical practice.