Peri-operative care considerations for primary total knee arthroplasty in the obese patient

In the United States an increasing obesity epidemic compounded with growth in total knee arthroplasty (TKA) utilization is increasing the incidence of TKA in the obese population. Arthroplasty surgeons are directly affected by the obesity epidemic and need to understand how to safely offer a range of peri-operative care for these patients in order to ensure good clinical outcomes. Preoperative care for the obese patient involves nutritional counseling, weight loss methods, consideration for bariatric surgery, physical therapy, metabolic workup with diagnosis, and management of frequent comorbid conditions. Obese patients must also be counseled on their increased risk of complications following TKA. A successful surgical result is dependent on early risk mitigation techniques including weight loss, co-morbidity management, and nutritional optimization. In the operating room several steps can be taken to improve successful outcomes when performing TKA on obese patients. Peri-operative techniques including adequate surgical exposure, component positioning, and implant selection play an important role in the longevity of the implant in the obese TKA population who are at risk for post-operative tibial loosening and increased re-operation rates. Appropriate weight-adjusted antibiotic dosing, sterile surgical techniques, wound closure and coverage are essential in reducing infection in this susceptible population. Post-operative care of the obese patient following TKA involves several unique considerations. Chronic pain and obesity are frequent comorbid conditions and post-operative pain control regimens need to be tailored to these patients to improve function and surgical outcome. Obese patients can have a higher rate of all complications compared to healthy weight. All infection and deep infection increased in obese patients and patients must be counseled on their risks pre-operatively to encourage an active role in risk mitigation in the peri-operative period.     

Bilateral vocal cord palsy after total thyroidectomy–A new treatment–Case reports

IntroductionDyspnea due to bilateral vocal cord palsy after total thyroidectomy (BVCPATT) is a life-threatening complication; nevertheless, we try to avoid tracheotomy.MethodsUsing normalized glottal area (NGA), we retrospectively studied 14 patients with BVCPATT. Nine patients without dyspnea were treated conservatively, while five with dyspnea received immediate bilevel positive air-way pressure (BiPAP) treatment. Both right and left recurrent nerves were grossly intact during surgery.ResultsThe mean NGA during inspiration of five patients with dyspnea was less than that of nine patients without (6.21 ± 1.57 (mean ± standard deviation) vs. 20.5 ± 9.5; p = 0.001). The mean age of patients with dyspnea was more than that of patients without (61.6 ± 15.6 vs. 38 ± 10.2; p = 0.007). Five patients with dyspnea that occurred at 0–8 days post operation recovered within 3–17 days after BiPAP.ConclusionDyspnea occurred in patients with BVCPATT who were relatively older. The mean NGA during inspiration in patients with dyspnea was less than that in patients without. BiPAP might be a new treatment for dyspnea.     

Novel implant for peri-prosthetic proximal tibia fractures

BackgroundRepair of peri-prosthetic proximal tibia fractures is very challenging in patients with a total knee replacement or arthroplasty. The tibial component of the knee implant severely restricts the fixation points of the tibial implant to repair peri-prosthetic fractures. A novel implant has been designed with an extended flange over the anterior of tibial condyle to provide additional points of fixation, overcoming limitations of existing generic locking plates used for proximal tibia fractures. Furthermore, the screws fixed through the extended flange provide additional support to prevent the problem of subsidence of tibial component of knee implant.MethodsThe design methodology involved extraction of bone data from CT scans into a flexible CAD format, implant design and structural evaluation and optimisation using FEM as well as prototype development and manufacture by selective laser melting 3D printing technology with Ti6Al4 V powder.ResultsA prototype tibia implant was developed based on a patient-specific bone structure, which was regenerated from the CT images of patient’s tibia. The design is described in detail and being applied to fit up to 80% of patients, for both left and right sides based on the average dimensions and shape of the bone structure from a wide range of CT images.ConclusionA novel tibial implant has been developed to repair peri-prosthetic proximal tibia fractures which overcomes significant constraints from the tibial component of existing knee implant.     

Revision arthroplasty for periprosthetic joint infections: When to consider one-stage versus two-stage protocols?

For chronic periprosthetic joint infection, two-stage exchange arthroplasty has long remained the gold-standard treatment, but has come under scrutiny of late. Recent studies have shown increased costs, unacceptably high rates of recurrence for resistant organisms, and lower than expected rates of eventual reimplantation for subjects treated in a two-stage fashion. While the appeal of single-stage exchange arthroplasty has grown, rigorous data is lacking for universal application for all infections. Improvements in patient selection with set criteria for appropriate use will better define a treatment algorithm for optimum periprosthetic joint infection management moving forward.