Issue 1 November 2014 English
Novel hybrid ACL reconstructions for elite athletes
Pushing forward research in multi-ligament knee injury
LESS IS MORE ‘ONE-SHOT’ DEFORMITY CORRECTION WITH NEW CIRCULAR FIXATOR
Metal toughness, ceramic resistance MAKING THE RIGHT CHOICE OF BONE GRAFT SUBSTITUTE
An arthroscopic approach to ankle fusion
Tackling orthopaedic needs in the developing world
A new venture
It is with great pleasure that I welcome you to the first edition of Healthshare Magazine. Our new publication will serve as a platform for the exhibition of technologies, cuttingedge practices and expert case reports from the whole spectrum of orthopaedic medicine. Within these pages, we will offer inside looks as to the brightest and best devices in the field, and share the procedures, techniques and perspectives that stem from leading centres all over Canada. As an industry, Smith & Nephew has always had a strong interaction with surgeons, nurses and other allied healthcare professionals, and we recognize that in the current climate, there is greater pressure than ever on cost-efficiency when selecting orthopaedic devices. To that end, while peer-reviewed journals are of course an essential component in the development of devices, we are acutely
aware that the time it takes to publish such information means we are missing out on an opportunity to keep medical professionals abreast of interesting technologies in the pipeline. Therefore one of the key aims of this publication will be to offer early glimpses of interesting new devices and procedural techniques, thereby fostering earlier interaction and the exchange of ideas between frontline medicine professionals and ourselves. And this is not limited to Canada, as we plan to expand our community of collaboration even further, building a more reciprocal and fluid relationship as we go. So on behalf of all my colleagues at Smith & Nephew, I do hope you enjoy reading Healthshare Magazine, and we look forward to welcoming you back for our future editions. Tim Bourne Managing Director Smith & Nephew Canada
4 An Olympic story
Robert Litchfield discusses his novel hybrid approach for ACL reconstruction in elite athletes.
8 ‘Time for new research’
Treatment of multi-ligament knee injury needs to play catch-up, says expert.
DESIGN & TECHNOLOGY
12 Porosity, form and function
Choosing the right properties to ensure an ideal bone graft subsitute.
18 Truly transformational
The Taylor Spatial Frame offers ‘one-shot’ treatment of complex limb deformities.
24 Durable, long-lasting, biocompatible
Revolutionary OXINIUM implants offer advanced characteristics for surface bearing, abrasion resistance and metallic hypersensitivity.
29 Arthroscopic ankle arthrodesis
Better outcomes, better wound-healing – so is the learning curve really an issue?
COMM U N I T Y & I N I T I AT I V E S
32 Mission Imperative
We take a look at CAMTA, Operation Walk Canada and the ongoing work that is providing essential care in developing countries.
Treating highperformance athletes 4
Dr Robert Litchfield Orthopaedic surgeon Fowler Kennedy Sport Medicine Clinic London, Ontario Dr Name Title
Kaya Turski Olympic freestyle skier
A NOVEL H YB RI D AC L REC ONSTR UC T I O N W HI C H UT I L I Z E D BOT H S Y NTH ETI C AND C ADAV ER -AL LO G R AF T I MP L AN T S DR EW A G REAT DEAL OF FOC US UP TO AN D D UR I N G T HE 2014 WINTER OLYMPI C S I N SOC H I , R US S I A, W I T H T HE FAT E OF A WORL D-L EADI NG ATH L ETE R E ST I N G O N I T S S UC C E S S .
ith such a high incidence of ACL injuries in high-intensity sports,1 elite athletes who sustain injuries represent a particular challenge for orthopaedic surgeons, especially in terms of their desire to return to extremely demanding activities in as short a time as possible. For Canadian freestyle skier Kaya Turski, her Olympic hopes were threatened in August 2013 when she tore her ACL during training. She was quickly referred to the care of Robert Litchfield, an orthopaedic surgeon at the Fowler Kennedy Sport Medicine Clinic in London, Ontario who works with a large number of elite athletes across a range of sports. “She had a very tight timeline to get ready for the Olympics,” Dr Litchfield told Healthshare Magazine.
While determined to compete in the Olympics, a tight timeline of around four months until the qualifying stage meant that Ms Turski’s recovery would have to be expedited if there was any hope of making it to Sochi. This presented a particular challenge for Dr Litchfield: “We would normally plan to have athletes back in action after around seven or eight months,” he said. A further technical challenge stemmed from the fact that Ms Turski had already undergone previous surgeries on both knees, which meant there were existing bone tunnels and some enlargement to work around, but even more crucial was that previous harvesting of hamstring autografts meant that no further autograft tissue was available – a particularly common problem for
Post-operative X-ray of Ms Turski’s knee following revision.
injury-prone elite athletes: “I can use another Canadian athlete as an example – Jan Hudec, who was a bronze medallist in the Super G event at Sochi,” said Dr Litchfield. “He had three reconstructions in one knee, including a double-bundle reconstruction, and also reconstruction in the opposite knee. By the time a person has been through these multiple revision reconstructions, autograft tissue sources will be very limited. We all would love to use them primarily, but at times we are forced to look elsewhere.” With this in mind, a synthetic ACL reconstruction was proposed by Ms Turski herself, but Dr Litchfield had concerns about this course of action. “For the most part there is a pretty negative connotation associated with the isolated use of synthetic ligaments.”2
“The hope was that the synthetic graft would be effective in the short-term, and the allograft would integrate in the longer term, and perhaps minimize the risk of having catastrophic failure in the knee, which would require revision,” he explained. After the surgery, Ms Turski was able to return to training on the snow after approximately three months – a vastly superior recovery time than the seven or eight-month window usually indicated.
“The hope was that the synthetic graft would be effective in the short-term, and the allograft would integrate in the longer term.” – Robert Litchfield
Torn ACL prior to revision
He added: “I was concerned that it would be, for one, a technical challenge, and secondly it would probably be a very short-term solution that may compromise the long-term function of her knee, especially important given that she is still young.” To that end – and with the pressing need to return Ms Turski back to her sport as quickly and effectively as possible – Dr Litchfield came up with a hybrid concept, combining a cadaver allograft with a synthetic ligament. ACL after revision
“[Athletes] are aware that a treatment may not be perfect, and may not be what is performed for everyone else, but given their very specific goals in life, they aren’t like everyone else.” – Robert Litchfield
Results continued to appear favourable, with Ms Turski earning third place in the Sochi slopestyle qualifying event in January, 2014 – a mere five months after her injury. The same month, she earned a gold medal in slopestyle during the X Games (Aspen, USA), once again demonstrating that the hybrid procedure was a great success in the short-term.
sporting events. For one, the chance to compete only comes around so often, thus athletes are especially keen to avoid missing out, which may have implications to the kind of treatment they are willing to undergo. “The eye-opening issue is that there are very few athletes at that level who are actually symptom free or injury free,” said Dr Litchfield.
Unfortunately, despite her knee remaining seemingly strong, Ms Turski’s Olympic hopes were dashed due to a reported flu-like illness during her time in Sochi.
“It’s all about managing the level of their injury. They are aware that a treatment may not be perfect, and may not be what is performed for everyone else, but given their very specific goals in life, they aren’t like everyone else.”
Reflecting on the short-term and long-term potential of the hybrid procedure used in the case, Dr Litchfield commented: “At this stage I have a moderate level of confidence in the procedure, in that Kaya has made it this far without any problems, despite there being many opportunities. But I’ve learnt over the years that the proof is in the pudding, so to speak, so I would suggest we still remain cautious.” In fact, since Ms Turski’s case, Dr Litchfield has not repeated the procedure for other elite athletes in his care as he would first like to see what longer-term results the procedure will offer. “Most of these athletes are very young,” he commented. “I’ve seen enough ruined knees in former elite athletes to know that they are often still very young when they retire from sport, so you want to ensure they can have a good life afterwards.” A core message arising from the case of Ms Turski is the unique nature of the Olympics and other global-scale
He added: “So it is easy to criticize people such as myself who are looking after these athletes because we do perform some procedures that may not be mainstream, but at the same time it is with full disclosure and knowledge from the athlete.” «
1. Griffin LY, Agel J, Albohm et al. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. J Am Acad Orthop Surg 2000;8(3):141-150 Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature 2. Legnani C, Ventura A, Terzaghi C et al. Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature. International Orthopaedics 2010;34:465–471
Treatment of multi-ligament knee injury
Dr Daniel Whelan Orthopaedic surgeon St. Michael’s Hospital, Toronto, Ontario
M ULT I-LIGAMENT KNEE I NJURY I S A C O MP L E X O R T HO PAE D I C P R E S E N TAT I O N , A ND SEV ERAL I MPORTANT FAC TO R S AR E K E Y W HE N C HO O S I N G T HE PAT HWAY OF T R EATMENT, ESPEC I AL LY W H E N C O N S I D E R I N G T HAT A N UMBE R O F T HE S E OP T ION S STI L L REMAI N C ONTROV E R S I AL TO T HI S DAY.
ulti-ligament knee injuries typically present following an acute knee dislocation, in which the high energy trauma experienced causes damage to several of the ligaments.1 A challenge follows not only in terms of ligament reconstruction or repair, but also in the balancing of the knee. Crucially, the injury carries with it profound implications for the viability of the leg itself, with high risk to surrounding soft tissue, nerves and blood vessels. To examine the past, present and future insights for multi-ligament knee injury treatment, Healthshare Magazine spoke to Daniel Whelan (St. Michael’s Hospital, Toronto, Ontario), an orthopaedic surgeon specializing in sports injuries and musculoskeletal soft tissue trauma.
“For a long time the treatment for this injury has lagged behind the treatment we’ve developed for other orthopaedic sports or soft tissue injuries.”
“For a long time the treatment for this injury has lagged behind the treatment we’ve developed for other orthopaedic sports or soft tissue injuries,” said Dr Whelan. “The reason for that is that we’ve never had the ability to move forward with prospective research because of the relative rarity of the injury.” This rarity is a key factor, with surgeons historically expected to see only a handful of cases a year within average-sized centres. “In my practice I see about 50 a year, but that’s because I work in a level 1 trauma centre in a large metropolitan area, and a lot of these injuries are referred,” he said. Crucially, times are now changing, and Dr Whelan stressed that the prevalence of multi-ligament knee injury has increased more recently for a number of reasons. A main factor is that more and more people are now surviving high-energy accidents and trauma (due to improvements in automobile safety, for example), but a rise in high intensity sports – and improvements in imaging modalities to detect injuries that may have previously been left untreated – can also be factored in.
– Daniel Whelan Healthshare Magazine
That being said, the number of multi-ligament knee injuries seen in any centre is still very small when compared to other orthopaedic injuries, thus it follows that consensus on the best course of treatment is surrounded by a relatively high level of controversy and debate. Some of these arguments include the use of repair versus reconstruction, allograft versus autograft use, and even operative versus non-operative treatment.2,3 While graft choice is more patient and centre-specific, large-cohort review data has suggested that an operative approach is indeed favourable.2,3 Similarly, primary open reconstruction of the lateral collateral and posterior cruciate ligaments has been shown to offer improved outcomes when compared to repair.2 As Dr Whelan outlined, perhaps the most fervent area of debate is the timeframe for operative treatment. There are two main schools of thought on this topic. The first, more traditional viewpoint is to immobilize the joint first with a brace, cast or fixator to promote stiffness and capsular healing. More modern thinking has led to a trend to try and stabilize the knee with ‘early’ surgery – typically defined as happening within the first three weeks post-injury –so that patients can embark on a program of mobility training and functional rehabilitation (during which selective use of preoperative and postoperative joint-spanning external fixation is advocated).2 Owing to the paucity of data surrounding the best treatment course, in 2007 Dr Whelan joined forces with like-minded colleagues from all over North America to establish a Knee Dislocation Study Group, tasked with further research into injury treatment outcomes.2 In 2009, the group published a systematic review of all the basic current evidence on multi-ligament knee injury and knee dislocation.2 “We came to the conclusion that early surgery probably afforded a better outcome,” said Dr Whelan.
Specifically, the review identified a number of key observations that pointed to early surgery as the preferential option in these sorts of cases. For one, Lysholm scores were consistently higher (20 points on average) when compared to a delayed surgical approach. The three-week window for early surgery is not derived arbitrarily, rather it has been noted previously as a critical period after which tissue becomes friable, scars hamper the identification of individual structures for repair, joint subluxation can become fixed and retraction prevents reduction of displaced tissue. 1 Interestingly, a very similar review conducted at the same time – and incorporating much the same literature – came to the conclusion that delayed (chronic) surgery offered beneficial outcomes, particularly in aspects such as anterior knee instability, severe flexion loss and stiffness.3 “This just highlights how much controversy still remains,” said Dr Whelan. He went on to note that in many cases the trauma presenting alongside multi-ligament knee injury can mean the choice to delay surgery is not an option. Life threatening issues (e.g. extensive tissue loss and vascular trauma) take obvious priority, followed by lower limb ischemia and vascular insufficiency. If a patient is stabilized, arterial flow to the foot is assessed, and in many cases an external fixator will be required to prevent an unstable knee posing a risk to the anastomosis. It follows that if the leg can be saved, surgical repair or reconstruction of the knee ligaments is pursued immediately. He also proposed that this shift to large-centre referrals would in turn suggest a number of things about the state of multi-ligament knee injury treatment. First, it is an example of the volume-outcome relationship that exists when undertaking the lengthy and complex procedures
required. Second, when taking into account the severe trauma that can present alongside multi-ligament knee injury – such as vascular problems, nerve damage and skin loss – it is clear that larger centres benefit from their in-house array of surgical staff specializing in plastic, peripheral vascular or nerve surgery.
“It is now time to move forward with some higher-level research to try and guide us to better answers as to the efficacy of early or delayed surgical treatment.” – Daniel Whelan But for cases where there is scope to delay surgery, Dr Whelan reiterated the necessity to have a clearer picture of the best treatment course, saying: “It is now time to move forward with some higher-level research to try and guide us to better answers as to the efficacy of early or delayed surgical treatment.” A large randomized trial focusing on this issue will require input from a large number of patients, which for such a rare injury means that it will in turn require input from a multitude of surgical centres. Dr Whelan stressed that thanks to a growing modern trend to refer patients to larger, specialized centres (which he experiences firsthand), proactive multi-centre collaboration is becoming a much more feasible option. Moving on to describe the outlook in pursuing more trial-focused research in the multi-ligament knee injury arena, Dr Whelan said that for this early stage, the first step employed by the St Michael’s Hospital team in Toronto – in collaboration with the Knee Dislocation Study Group – has been to implement an outcome score more specific to knee dislocations and multi-ligament knee injury. This follows on from observations that previous scores were not fully picking up on symptoms that patients were experiencing, especially in the case of associated polytrauma and nerve or vascular injury. On the back of this new outcome score, the team has started their first randomized trial looking at early- versus delayed-physiotherapy after repair. “We started with the physiotherapy question because we really couldn’t get consensus amongst groups of surgeons as to whether they felt comfortable delaying or performing operations acutely, so we thought the physiotherapy question would be a bit more palatable, and would offer us a better opportunity to get more patients into a randomized trial,” Dr Whelan explained.
to enroll in a larger, randomized trial, as well as typical exclusion/inclusion criteria. This will then hopefully lead to a significant trial of early versus delayed surgery in the near future. Moving on to discuss other areas of study, Dr Whelan spoke of the importance in assessing the risks for peroneal nerve injury following knee dislocation. Recent work has estimated the incidence of concomitant neurological injury in this setting to be between 10 and 40%, with the common peroneal nerve most at risk, thus there can be a considerable morbidity impact (especially in males, heavier patients or those with concomitant fracture of the fibula head).5 Another planned area of study includes the type of graft used in treatment. Specifically, rather than the question of autograft versus allograft use, Dr Whelan emphasized that a more pressing issue is the availability and type of allograft material in general (especially given many smaller centres or less-equipped countries can have limited or zero access to allograft tissue). “You’re not really left with a lot of choice in terms of a multi-ligament injury, because there’s not a lot of options by which to reconstruct the ligament,” he said. “The debate now, in my circle anyway, is what type of allograft do you use. The preparation of allograft is also very topical right now. Should you use a irradiated allograft, or non-irradiated? Should you use a soft tissue allograft or one that has a bony attachment?” Ultimately, the heterogeneity of current treatment practices for multi-ligament knee injury (early versus delayed surgery, repair versus reconstruction, graft usage etc.) means that studies will need to incorporate a substantial patient population in order to offer better statistical power. Dr Whelan reiterated that, thankfully, data pooling from a number of key centres will hopefully hold the key to ushering in a new era of extensive trial research within the field. «
1. Levy BA, Dajani KA, Whelan DB et al. Decision Making in the Multiligament-Injured Knee: An Evidence-Based Systematic Review. Arthroscopy 2009;25(4):430–438 2. Levy BA, Fanelli GC, Whelan DB et al. Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction. J Am Acad Orthop Surg 2009; 17:197–206 3. Peskun CJ and Whelan DB. Outcomes of Operative and Nonoperative Treatment of Multiligament Knee Injuries: An Evidence-based Review. Sports Med Arthrosc Rev 2011;19:167–173 4. Mook WR, Miller MD, Diduch DR et al. Multiple-Ligament Knee Injuries: A Systematic Review of the Timing of Operative Intervention and Postoperative Rehabilitation. J Bone Joint Surg Am. 2009;91:2946–57 5. Peskun CJ, Chahal J, Steinfeld ZY et al. Risk Factors for Peroneal Nerve Injury and Recovery in Knee Dislocation. Clin Orthop Relat Res (2012) 470:774–778
The single centre trial has currently recruited around half of the projected 40-patient cohort, and will serve as a pilot investigation, affording feasibility data with which to assess how well the new outcome score performs, as well as helping to predict how many patients can be expected
DESIGN & TECHNOLOGYâ€‚
No substitute for the right bone graft material
DESIGN & TECHNOLOGY
Dr Sébastien Paratte Orthopaedic surgeon Institute for Locomotion, Sainte Marguerite Hospital, Aix-Marseille University, Marseille, France
BON E G RAF T SUB STI TU TES A R E A K E Y PAR T O F D E AL I N G W I T H BO N E LO S S IN CO MPL EX ORTH OPAEDI C CAS E S , AS W E L L AS I N T R AUMA AN D C O MP L E X R EVIS ION PROC EDURES. H OW E V E R , N OT AL L S UBST I T UT E S AR E BO R N EQ UAL , A N D TH E C H ARAC TERI STI C S O F E AC H P R O D UC T C AN VAR Y W I D E LY, W I T H A H UG E I MPAC T O N O UTC O ME .
o find out more about what makes a good bone graft substitute, Healthshare Magazine spoke to leading orthopaedic surgeon Sébastien Parratte (Institute for Locomotion, Sainte Marguerite Hospital, Aix-Marseille University, Marseille, France) about his expe rience with, and requirements for, a bone void filler. Dr Parratte has had a long history of tackling the most complex and challenging orthopaedic cases. After completing his residency, he embarked on two fellowships: the first in Marseille, with a focus on reconstruction, while the second was a one year research fellowship in hip and knee reconstruction at the Mayo Clinic in Rochester, USA.
As Dr Parratte works at a university hospital, and hence a tertiary referral center, he is sent complex orthopae dic cases on a regular basis. Or, in his own words: “Bone loss is our daily practice.” That is why, at some point, Dr Parratte needs to use bone graft substitutes (BGSs). When he began to perform the kinds of procedures that require bone void fillers for cavitary defects, he relied initially on allografts, typically for hip revision cases. Dr Parratte found cancellous allografts an interesting proposition, although not particularly convenient. In addition, the infection risk posed by allografts, such as sepsis, was a concern. Less problematic solutions to the issue of missing bone were therefore required, which led to the choice of BGS.
Describing the main requirements of a BGS, Dr Parratte commented: “The most important quality is that it should be safe. By safe, I mean it should, of course, not bring with it any risk of infection, such as that seen with an allograft.” He continued: “It should also not modify the strength of the bone close to the injection site. This is obviously not safe because, if one part of the bone is too strong, the other part can break. To put it another way, if the modulus of elasticity is altered due to the injection of the bone substitute, that is not good. Finally, safe also means that it should not cause any healing problems, by which I mean in terms of both fractures and healing of the skin.”
DESIGN & TECHNOLOGY
Returning to the most desirable attributes of a BGS, Dr Parratte said: “The next most important quality is that it is easy to use, and, last but not least, that it should become bone.” Although the latter sounds like an obvious, and basic, requirement, Dr Parratte pointed out that it could not always be taken for granted that a BGS would have bone-like qualities. As he explained, before the current crop of products there were three previous generations of bone substitute, none of which had ideal properties.
how pleased he was when he discovered calcium phosphate bone graft substitute. “This perfectly met my expectations, as it was convenient, easy-to-use, off-the-shelf and the product, at least on the experimental side, became bone, due to the presence of micro-, meso-, and macroporosity,” he said. Describing how he incorporated calcium phosphate BGS into his practice, Dr Parratte continued: “Initially, I used it in trauma cases. Examining the evolution of fracture healing, I observed that the product did not interfere with bone healing and, moreover, that it reinforced the stability of the metal pins I had placed. That was something I really liked.”
We observed on histological examination that the product indeed became bone, as it was surrounded by a bone–laminar border and by autograft cells.” Having now used calcium phosphate BGS in a large number of cases and in a wide variety of scenarios, Dr Parratte has a series of tips for surgeons wanting to use it themselves. The first is that the surgical technique should not be changed when using the novel product. “Second, you should prepare the area where you are going to inject the graft,” he said.
“With the very first generation of injectable bone substitute, more “That means that you have to clean than 10 years ago, disappointing the area and remove all the tissue or results in terms of bone formation fibrous remnants. You have to prepare were observed,” he said, adding that, the surface of the bone to clean it, because of a lack of and then you have to macro- and meso dry the surface where porosity, cells were you are going to inject “[This] is one of the only bone substitutes unable to penetrate the bone substitute.” that has micro-, meso- and macroporosity, the BGS, leading to the formation of a Dr Parratte continued: which will promote bone formation in more “stone”-like “As it is injectable, you around the product.” substance. will need a cannula to – Sébastien Parratte inject the product into Dr Parratte continued: the area that you want “The second generato seal, which means tion of bone sub you have to select stitutes had the consistency of Nevertheless, this novel BGS had the proper length, shape and size of granules or aggregate in concrete, to satisfy Dr Parratte that it delivered cannula to easily reach the area that which became like sand in the bone. on his expectations before he could you want to graft.” This means that the bone cells were use it more widely. He explained: unable to penetrate the substitute. “My first question was: Is it easy to He cautioned that calcium phosphate The third generation was highly use and safe? The answer was: ‘Yes’. BGS is primarily for use with cavitary injectable but did not have any defects, and should not be used to mechanical properties. Consequently, “Then I used the product for more treat segmental defects. He also it was like toothpaste, and it stayed complex tibial plateau fractures, and warned that, once it has been like that, without hardening or my next question was: Does it really injected, it should not be touched, reinforcing the structure.” become bone? I took bone biopsies as it will modify the crystallization during hardware removal from some process. “So you should inject it and With these disappointing previous procedures in which I had placed the leave it in place,” said Dr Parratte. results to mind, Dr Parratte stressed graft one or two years previously.
DESIGN & TECHNOLOGY
“Lastly, when I started using it, I was expecting to see the beginning of hardening of the product before closing. But as the setting time is 24 hours, we do not see even the starting of the hardening, which is not a problem at all.” What differences does Dr Parratte believe that using an injectable self-setting calcium phosphate BGS makes to perioperative outcomes? “First, it allows me to accelerate recovery of the patient’s range of motion,” he noted.
calcium phosphate BGS, such as STRUCSURE™ CP (Smith & Nephew; see following page for additional information), over other products? He said: “They should use it first “The mechanical properties are very of all for its interesting because its compressive strength practicality, as the mix lies between that of cortical bone and is very easy spongiform, or cancellous, bone.” to make.
“For example, in cases of tibial plateau fracture, I no longer have to brace my patients. It means I do not have any limitations in terms of the mobilization of the knee following a tibial plateau fracture. I encourage my patients to get active very early on, and without any limitations in knee mobilization.” Looking at the long-term benefits, Dr Parratte continued: “Injecting some bone substitute will increase the bony integration of the implant or prosthesis. In terms of the internal fixation, that will probably optimize and stabilize fixation, which means that we will obtain more anatomical results. This is very important for the long-term function of the joint, and will regenerate the bone that was destroyed during the fracture or before the revision.” One of the key features of a calcium phosphate BGS is that it allows immediate hardware placement during the procedure. “The first point is that it makes it very easy to use,” said Dr Parratte. “That means that I
can do the procedure as normal, drilling for my screws and measuring. I then inject the graft, and then I insert the screws, which is basically exactly like a normal procedure.
– Sébastien Parratte
The second point is that I am more confident in my screw fixation when I use it in cases of ‘bad bone’, such as in the osteoporotic patient.” He continued: “In these types of cases, I previously had to use the classical orthopaedic cement – PMMA [polymethyl methacrylate]. This is not good at all for the border of the bone. Because I know I can put the hardware in immediately after the fixation, I use calcium phosphate BGS instead of bone cement for fracture fixation in the elderly. It is much better because it becomes bone.”
“Second, the mechanical properties are very interesting because its compressive strength lies between that of cortical bone and spongiform, or cancellous, bone. Third, it is one of the only bone substitutes that has micro-, meso- and macroporosity, which will promote bone formation in around the product.” «
Dr Parratte said: “I can also do tibioplasty with this bone graft substitute. Many people carrying out these procedures use PMMA, but I am able to use it via balloonplasty. I inject the substitute and put my screws in to facilitate fixation, and it’s not a problem at all.” Finally, why, in Dr Parratte’s opinion, would a surgeon who does not have much experience with using BGSs, or is new to the concept, choose a
DESIGN & TECHNOLOGY
Be sure about your choice of bone graft substitute T
he increasing number of bone-grafting procedures performed every year has stimulated great interest in developing bone graft substitutes, including natural, synthetic, human and animal-derived materials.1 The American Academy of Orthopedic Surgeons (AAOS) states that the ideal bone-graft substitute is: biocompatible; bioresorbable; osteoconductive; osteoinductive; structurally similar to bone; easy to use; and cost-effective.1 They also note that the available products have different compositions and different mechanisms of action, and it is therefore reasonable to assume that not all bone-graft substitute products will perform the same. STRUCSURE CP™ is an injectable, hard-setting calcium phosphate bone graft substitute. It is designed to be placed or injected into bony voids or gaps in the skeletal system, and is supplied in an easy-to-use, all-inclusive closed mixing system. A key feature of STRUCSURE CP is that it sets gradually. Although implants can be placed immediately after injection, and up to two hours post-injection, the product hardens fully only after 24 hours at body temperature. This offers the surgeon the flexibility of hardware insertion before or after use of STRUCSURE CP bone graft substitute. Crucially, the calcium phosphate mixture in STRUCSURE CP becomes calcium-deficient apatite when hardened, similarly to native bone apatite crystals. This means that STRUCSURE CP gradually remodels into bone, aligned with natural bone healing processes, and achieves a compressive strength of 24 MPa. Furthermore, STRUCSURE CP is able to resist washout by biological fluids, such as via blood flow.
Central to the benefits of STRUCSURE CP is its porosity. It has microporosity (<10 µm), which allows for circulation of biological fluids, bringing nutrients and oxygen to cells and carrying waste products away. It also has mesoporosity (10–100 µm), which improves interconnectivity between pores, and macroporosity (>100 µm), which allows for cell proliferation. STRUCSURE CP is intended for bony voids or defects that are not intrinsic to the stability of bone structure, such as trauma and reconstruction defects. These include metaphyseal fractures of the tibial plateau, distal radius, calcaneus and humerus, bone cysts, total hip and knee arthroplasties, revision hip and knee arthroplasties, hardware removal, and iliac crest backfill. There have been a number of studies that have demonstrated the efficacy of calcium phosphate bone graft substitutes. For example, a meta-analysis of randomized trials showed that patients with metaphyseal fractures managed with calcium phosphate had a significantly lower (68%) prevalence of loss of fracture reduction versus patients who received autograft, as well as less pain (56%) at the fracture site.2 Furthermore, a study comparing injectable calcium phosphate bone graft substitute and autograft in patients with tibial fractures revealed that there was a significantly lower rate of articular subsidence (9%) with calcium phosphate bone graft substitute versus autogenous iliac bone tract (30%), and appeared to be a better choice for unstable fractures.3
1. Greenwald AS, Boden SD, Robert LB et al. The Evolving Role of Bone-Graft Substitutes. American Academy of Orthopedic Surgeons 77th Annual Meeting. March 9-13, 2010; New Orleans, LA. 2. Bajammal SS, Zlowodzki M, Lelwica A et al. The use of calcium phosphate bone cement in fracture treatment. A meta-analysis of randomized trials. J Bone Joint Surg Am. 2008;90(6):1186-96. 3. Russell TA, Leighton RK, Group A-BSMTPFS. Comparison of autogenous bone graft and endothermic calcium phosphate cement for defect augmentation in tibial plateau fractures. A multicenter, prospective, randomized study. J Bone Joint Surg Am. 2008;90(10):2057-61.
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DESIGN & TECHNOLOGYâ€‚
A step forward in correcting difficult paediatric limb deformities
DESIGN & TECHNOLOGY
Dr Marie Gdalevitch Orthopaedic surgeon Montreal Children’s Hospital, the Montreal General Hospital & the Shriners Hospital
T R EAT MENT OF C OMPL EX L I MB D E FO R MI T I E S I N PAE D I AT R I C PAT I E N T S US E TO R EQUIRE MU LTI PL E OR V I SI TS AN D YE AR S O F P L AN N I N G , BUT A T EC HN O LO GY T HAT I S FL EXI B L E AND ADAPTABL E E N O UG H FO R E V E N T HE MO ST D I F F I C ULT CASES MEANS TH AT TH E C O R R EC T I O N P R O C E S S I S T R AN S FO R ME D .
he Taylor Spatial Frame (TSF) is a circular, metal frame with two rings that connect to six telescopic struts. These can be independently lengthened or shortened relative to the rest of the frame, allowing for six different axes of movement. Alongside the ability to correct difficult congenital deformities and trauma cases, the external fixation enables percutaneous reduction and fixation, with minimum impact on soft tissues. To find out more about this innovative technology, we spoke to Marie Gdalevitch, an orthopaedic surgeon at the Montreal Children’s Hospital, the Montreal General Hospital & the Shriners Hospital in Montreal, Quebec. Dr Gdalevitch completed both her medical degree and her orthopaedic residency at McGill University, Quebec. She subsequently trained in limb lengthening and reconstruction in Baltimore, and completed another year-long fellowship in paediatric orthopaedics in Sydney, Australia. When she returned to the Shriners Hospital in 2011, the team started to use the TSF for limb reconstruction. Dr Gdalevitch explained that the deformities encountered in paediatric ortho paedics are often complex, as they are typically in more than one plane. The result is that both lengthening and deformity correction is often required simultaneously. “The previous apparatus we used was limited by having to return to the operating room multiple times to make frame adjustments simply to complete one correction or to move onto another deformity in another plane,” she said. “You would be constantly chasing your tail, because, after you finished correcting one part, you could end up integrating some deformities into your correction if it was not perfect.” Clinicians would therefore return multiple times to the operating room or end up dividing up the corrections over several years.
Figure 1: 13-year-old child with X-linked familial hypophosphatemic rickets.
DESIGN & TECHNOLOGY
“You can continuously correct without having to go back to the operating room. That means you can get it just right.” – Marie Gdalevitch
“With the TSF, you can do it as a ‘one-shot’ deal, instead of having multiple events,” Dr Gdalevitch commented. “It’s very powerful and it’s revolutionized limb reconstruction in a massive way.” She continued: “When I came back to Shriners, I encountered several very challenging cases in which having TSF technology was critical to being able to address these cases in one go.” She added that, crucially, the complexity of the deformity does not change the principles of using the TSF frame. Furthermore, Dr Gdalevitch noted that several papers have shown that the accuracy of correction is much higher with the TSF. “You don’t compromise as much as you would with the other system, because you can continuously correct without having to go back to the operating room,” she said. “That means you can get it just right.” One type of complex case Dr Gdalevitch treats is rickets, with patients tending to have massive deformities of the lower limbs secondary to their bone abnormalities. “We typically do the correction at the end of growth, so they won’t re-bow,” Dr Gdalevitch commented.
Figure 2. Severe genu varum, with the TSF used to correct the tibial deformities.
DESIGN & TECHNOLOGY
She continued: “The deformity correction is complicated because it is multiplanar and oftentimes you have to break the bone in more than one place to be able to make it straight,” Dr Gdalevitch said. “These can require stacked frames, perhaps a double frame or even triple frame. “To address those kinds of cases, I’ll try to correct one bone acutely. For the femur, I would use fixator-assisted nailing or plating to get the most accurate correction possible and then do the remainder of the correction using the TSF in the tibia. Having a frame from knee to toe is a bit cumbersome for patients, therefore addressing the limb reconstruction by combining acute and gradual corrections helps. If the acute correction is a couple of degrees off, I’ll be able to compensate for that with the TSF. Furthermore with the TSF, the patient can weight bear, so you can get a standing radiograph to perfectly assess the mechanical axis of the limb.
One case Dr Gdalevitch treated recently was a 13-year-old child with X-linked familial hypophosphatemic rickets. The child had knee pain and difficulty walking. Examination revealed severe genu varum, with knee flexion contractures bilaterally and a internal thigh-foot angle of 40º bilaterally (Figure 1). Fixator-assisted nailing allowed correction of the femoral deformities, while the TSF was used to gradually correct the tibial deformities (Figures 2 and 3). But is the TSF suitable for every case? “If you are just doing a pure lengthening, you could argue that you could still do that with the Ilizarov apparatus,” Dr Gdalevitch said. “However, most people who do limb reconstruction do what we call a ‘hybrid’ technique. For this, you could start off using the same rings as you would for the TSF, but use the straight threaded rods from the Ilizarov to start the lengthening.
“With the TSF, you can do it as a ‘one-shot’ deal, instead of having multiple events. It’s very powerful and it’s revolutionized limb reconstruction in a massive way.” – Marie Gdalevitch
DESIGN & TECHNOLOGY
Figure 3. Before and after correction of both the femoral and tibial deformities.
“Often in these cases, deformity accumulates over time because you can’t be 100% perfect. If you are a couple of degrees off in a 1-cm lengthening, you won’t notice. However, in an 8-cm lengthening, that couple of degrees becomes exponentially more dramatic in terms of the ensuing deformity.” Dr Gdalevitch observed that, instead of going back to the OR, you simply switch out the threaded rods for the TSF struts in the clinic and then use the computer program to correct whatever deformity occurred during the lengthening. “I’d say that’s really the only time when I wouldn’t start directly by using the TSF,” Dr Gdalevitch said. “As you can never tell what’s going to happen during treatment, nowadays most surgeons would prefer to have the TSF as an option since it gives you so much more flexibility and avoids having to go back to the operating room. Dr Gdalevitch also noted that, given the fact that with the TSF you can correct deformities in multiple planes, it has also revolutionized foot and ankle deformity correction. This was problematic with the Ilizarov apparatus due to the multiple readjustments required.
The main draw back to the TSF is the elevated cost compared to the Ilizarov. Introducing the TSF to the Shriners hospital required a business plan demonstrating its cost-effectiveness in the long run. “The problem in the hospital setting is that one hand doesn’t talk to the other,” Dr Gdalevitch commented. “In other words, the cost of the equipment comes from one budget, while the cost of readmission comes from another budget. “If you look at the big picture, you can definitely see that the cost benefit is there, since the cost of re-operation and re-admission far outweigh the initial cost of the equipment, not to mention the medical benefits to the patients. But if you only look at the operating room budget, it is not apparent.” Dr Gdalevitch is currently undertaking a study to examine the cost impact of the TSF versus the Ilizarov taking into account returns to the OR and other complications, which could demonstrate substantial cost benefits to the hospital and health care system. «
DESIGN & TECHNOLOGY
1 in 10 patients suffer a complication post-surgery1
Increased cost to the hospital through extra surgical procedures and prolonged hospital stay
Prolonged hospital stay and increased mortality and morbidity2
Haematoma formation Seroma formation Surgical dehiscence Deep wound infection
Knee replacement SSI = Additional 8 days in hospital3
Knee replacement SSI = Can add 50% to the cost of surgery3
Negative Pressure Wound Therapy can help you manage your high risk patients
Reducing complications in high risk patients Reduction in seroma volume5
Key patient risk factors4
Reduction in deep infection6
Reduction in dehiscence6
NPWT rgery Su
PICO is an incision management system that provides Negative Pressure Wound Therapy (NPWT) and has been proven to prevent post operative complications7,8 References 1. Health and social case information centre. Proms speical topic-complications after surgery April 2010 to March 2014. 2. Schimmer, C et al., Prevention of Sternal Dehiscence and Infection in High-Risk Patients: A Prospective Randomized Multicenter Trial. Ann Thorac Surg 2008;86:1897–904. 3. Jenks et al., Clinical and economic burden of surgical site infections (SSI) and predicted finacial consequences of elimination of SSI from an English hospital. Journal of hospital infections 86 (2014) 24-33. 4. Fowler et al., Clinical predictors of major infections after cardiac surgery. Circulation 2005. doi 1161 Circulation. 104. 5. Pachowsky et al., NPWT to prevent seromas and treat surgical incisions after total hip arthoplasty. International orthopaedics. DOI 10.1007/S00264-011-1321-8. 6. Stannard JP et al., Incisional Negative Pressure Wound Therapy after high-risk lower extremity fractures. J Orthop Trauma. 2011;26(1):37–42. 7. Hudson DA et al., Simplified Negative Pressure Wound Therapy: Clinical Evaluation of an ultraportable, no-canister system. Int. Wound J. 2013. May 7. DOI: 10.1111/iwj.12080. 8. Karlakki S. Negative Pressure Wound Therapy in the management of surgical incisions. A review of the evidence and mechanism of action. Presented Negative Pressure meeting Frankfurt 2014. ™Trademark of Smith & Nephew
© Smith & Nephew May 2014
Healthshare Magazine 23 For patients. For budgets. For today.™
DESIGN & TECHNOLOGYâ€‚
Advanced bearing surfaces for arthroplasty 24
DESIGN & TECHNOLOGY
Dr Julio Fernandes Orthopaedic surgeon Hôpital du Sacré-Cœur de Montréal, Quebec
R EVOLU TI ONARY B EARI NG SU R FAC E S T HAT C AN O F F E R A C O MBI N AT I O N O F P R OLONGE D DURAB I L I T Y AND I MPR OV E D W E AR R E S I STAN C E AN D BI O C O MPAT I B I L I T Y A R E A N I MPORTANT STEP I N PROV I D I N G LO N G E R -L AST I N G J O I N T R E P L AC E ME NTS TH AT C AN L I V E UP TO T HE R EQ UI R E ME N T S O F MO D E R N L I F E .
he ultimate longevity and biocompatibility of individual arthroplasty systems stem from a number of factors that include material design, surgical implantation methodology and individual patient criteria.1 To facilitate the best bearing surface possible, much time and testing has been invested in improving the materials used in such implants.
the need for revision,” explained Julio Fernandes, an orthopaedic surgeon at the Hôpital du Sacré-Cœur de Montréal, Quebec.
Both metal-on-polyethylene (MoPE) bearings and metal-on-metal (MoM) bearings have seen their place in the surgical armamentarium, each with their own set of apparent advantages and disadvantages. More conventional MoPE interfaces have been shown to suffer from excessive wear, leading to a resurgence of MoM bearings that are more resistant to wear-induced osteolysis.1,2 However, more extensive use of metallic surface components has more recently been postulated as a major cause of abnormal soft tissue reactions – namely cellular toxicity and hypersensitivity – that can in turn lead to the need for implant revision.1,2
Proposed necrotic and inflammatory changes caused by cobalt-chrome particles include pseudotumors (cystic or solid), aseptic lymphocytic vasculitis-associated lesions (ALVAL), macroscopic tissue staining and other adverse metal debris reactions.2
This concept of metallic hypersensitivity in patients is an emerging concept that has drawn the focus of many researchers. “People who have metal hypersensitivity might react to their implant quite badly – leading to
“Nickel hypersensitivity in particularly seems to be pretty common, with approximately 20% of the population showing sensitivity.”3
Referring to his experience of patient outcomes, Dr Fernandes stressed that while studies have pointed to approximately 83% of TKA patients being satisfied with their knee implant,4 identifying why the remaining 17% are dissatisfied is a difficult task: “There isn’t always a cause we can find,” he said. “There may be no infection, no complex regional pain syndrome, no imbalance, no instability, no malrotation, no referred pain, no over stuffing. So if everything seems technically sound, what is the cause of the problem?”
DESIGN & TECHNOLOGY
Gordon Hunter Group Manger of Materials Quality and Strategic Manufacturing While the prevalence and mechanism of metal hypersensitivity is not fully understood, there have been suggestions of an adaptive lymphocytic immune response.1 For Dr Fernandes, an important next step in understanding more about the prevalence of adverse responses to metallic components is the screening of potential arthroplasty patients. “We have examined 33 patients following painful total knee replacements – which is a fairly high number for a single practice – who reacted to one or several metals” he said. “We then revised around 15 of these patients, and out of these 15, 13 have shown great improvement in terms of pain, swelling, and function.”
“If people are hypersensitive to nickel, to chrome, and maybe to some titanium alloys, then perhaps zirconium alloys will provide us with a better outcome.” – Julio Fernandes
The next step in this screening work will be a prospective study on a large cohort of around 660 patients, who will be screened before total knee replacement, then randomly assigned to either regular cobalt-chrome implants or a more biocompatible zirconium alloy that is thought to cause less hypersensitivity. “If people are hypersensitive to nickel, to chrome, and maybe to some titanium alloys, then perhaps zirconium alloys will provide us with a better outcome,” he commented. “At least we might be able to enlighten the discussion a little bit.” In addition, Dr Fernandes touched upon the role that elevated levels of metal ions might have in the overall understanding of the adverse effects caused by implants, underlining that not everyone will react to elevated levels, while others may react aggressively. Indeed, testing for metal ions may help assist in understanding the long term effects of these ions on the body.1,2 “This is an area where there is still controversy,” added Dr Fernandes. “People react either by looking at it as something they hadn’t considered, or they refute it. But say you believe there is metal hypersensitivity, and suppose you want to take that into consideration when you choose the implant – and suppose 20% of people have hypersensitivity to regular alloys – then you can decide what material choice would be better to implant in each individual case.”
Smith & Nephew
OXINIUM Representing the cutting-edge for advanced bearing surface technology, OXINIUM◊ products (Smith & Nephew, Inc., Memphis, TN, USA) are made of a novel metal-ceramic material that was developed to address the strength, longevity and biocompatibility of hip and knee implants. OXINIUM implants are comprised of a zirconium alloy metal substrate, with a chemically-bonded zirconium oxide ceramic outer layer. This ceramic layer is formed via high-temperature oxidation of the zirconium, resulting in a layer with superior hardness and abrasion-resistance.5 “You get the toughness of the metal, but the wear properties of the ceramic,” explained Gordon Hunter, Group Manger of Materials Quality and Strategic Manufacturing at Smith & Nephew. The ceramic layer itself is tightly bound to the metal surface, meaning that even if the metal is stressed to the point where the ceramic starts to break, the ceramic will break apart rather than break away. “It is more tightly attached to the metal underneath than it is to itself,” said Dr Hunter. Crucially, OXINIUM material contains extremely low levels of nickel, cobalt and chromium, thus it represents a biocompatible surface for those suffering from metal hypersensitivity, which should reduce adverse tissue response, and therefore the need for implant revision.6 In addition, the counterface of the complete implant system features a polyethylene polymer, which means that no further metallic sensitivity should be endured. When the OXINIUM oxidized zirconium bearing is paired with a highly crosslinked polyethylene (XLPE) bearing, the combination is called VERILAST◊ technology. The VERILAST system has been designed with strength, durability and longevity very much at the forefront. “One of the most important factors is how to improve survivorship, so that patients can avoid having revisions,” said Dr Hunter.
â€‚ DESIGN & TECHNOLOGY
30 years VERILAST @
60 40 20
CoCr/CPE @ 3
Average volumetric wear (mm 3 )
VERILAST is advanced bearing technology for LEGION Primary Total Knee replacement which has data to demonstrate 81% wear reduction over a 30 year period as compared to wear simulator data seen for a traditional bearing couple for an estimated three years.
After simulating 3 years of wear, the average volumetric wear of VERILAST couples (2.67 mm3) was approximately 98% lower than the CoCr/CPE couples (120.42mm3)
Moreover, after simulating 30 years of wear, the average volumetric wear of VERILAST couples (22.78mm3) was approximately 81% lower than the CoCr/CPE couples after 3 years of wear (120.42mm3)
Based on laboratory wear simulation testing, the LEGION Primary Knee System with VERILAST technology is expected to provide wear performance sufficient for 30 years of actual use under typical conditions. Data on file at Smith & Nephew. The results of in-vitro wear simulation testing have not been proven to quantitatively predict clinical wear performance. Also, a reduction in total polyethylene wear volume or wear rate alone may not result in an improved clinical outcome as wear particle size and morphology are also critical factors in the evaluation of the potential for wear mediated osteolysis and associated aseptic implant loosening. Particle size and morphology were not evaluated as part of the testing. Other risks can include loosening, fracture, dislocation and infection.
DESIGN & TECHNOLOGY
“Now we are seeing people in their 30s having joint replacements...it is important that we focus very strongly on survivorship issues and the durability of these materials.” – Gordon Hunter
“Years ago it would be rare for someone to have a joint replacement before 65, and their subsequent life expectancy was about 10 or 15 years. Now we are seeing people in their 30s having joint replacements, and if they are going to live into their 90s it is important that we focus very strongly on survivorship issues and the durability of these materials. Otherwise young people will be looking at two of three revisions in a lifetime, which could have a serious impact on their lifestyle.”
“What we wanted was a product that would not cause a problem for any patient,” continued Dr Hunter. “If that patient would have done well with conventional implant materials – i.e. metal and conventional plastic – they should still do well with VERILAST technology. And if there is a patient who would not have done well with conventional technology, then this new system should provide advantages for them, and perhaps improve their implant longevity.
This present-day need for arthroplasty in younger patient populations may stem from a number of factors including a propensity for high-intensity sports, increased obesity prevalence or injury from trauma that would have previously been fatal (for example severe automobile accidents). Nevertheless, younger patients may also present heightened expectations of what a replacement joint will permit them to do (returning to high-impact sports, for example), as Dr Hunter described: “These patients are going to do whatever they want to, and their doctors are going to treat them as best they can. So if we can arm them with more options to treat these patients, the better off everyone is going to be in society. That’s why we need to focus on making higher-demand products.”
“Another great feature of OXINIUM implants is that we make them in the same designs as cobalt chrome, so the systems are interchangeable from a surgical standpoint. There is no change in surgical procedure, and there is no learning curve required to use them. Surgeons are able to alternate back and forth between metal components and OXINIUM components and proceed normally, providing a custom treatment that matches the patient’s needs.”
As Dr Hunter noted, the primary reason for implant revision stems from wear between metallic and poly ethylene components, leading to aseptic loosening and osteolysis.7 With this in mind, the pioneering XLPE component of the VERILAST system is a crucial facet of its low-wear profile, which has minimal friction and abrasion when combined with the ceramic OXINIUM surface.
Alongside simulator studies to test the mechanical longevity of VERILAST technology (both before and after its commercial launch), future clinical data will be evaluated confirm laboratory testing, and ultimately assess how the advantages of VERILAST technology can assist with improved implant survivorship. « ◊ Trademark of Smith & Nephew
1. Kwon Y-M, Jacobs JJ, MacDonald SJ et al. Evidence-Based Understanding of Management Perils for Metal-on-Metal Hip Arthroplasty Patients. The Journal of Arthroplasty 2012; 27(8):20-25 2. Haddad FS, Thakrar RR, Hart AJ et al. Metal-on-metal bearings: The evidence so far. J Bone Joint Surg 2011;93-B:572-9 3. Kręcisz B, Kieć-Świerczyńska M and Chomiczewska-Skóra D. Allergy to orthopedic metal implants - a prospective study. Int J Occup Med Environ Health. 2012 Sep;25(4):463-9 4. Dunbar MJ, Richardson G and Robertsson O. I can’t get no satisfaction after my total knee replacement: rhymes and reasons. Bone Joint J. 2013 Nov;95-B (11 Suppl A):148-52. 5. N.P. Sheth, P. Lementowski, G. Hunter, and J.P. Garino, “Clinical applications of oxidized zirconium”, J. Surg. Orthop. Adv., 17 (1), 2008, pp. 17-26. 6. Garrett S, Jacobs N, Yates P, Smith A, Wood D. Differences in metal ion release following cobalt-chromium and oxidized zirconium total knee arthroplasty. Acta. Orthop. Belg. 76(4), 513-520 7. Rajaee SS, Trofa D, Matzkin E, Smith E. National trends in primary total hip arthroplasty in extremely young patients. J Arthroplasty. 2012;27:1870-1878.
New study merits of ankle arthroscopy ARTH ROSC OPI C ANKL E AR T HR O D E S I S ( F US I O N ) O F F E R S S E V E R AL P OT E NTI AL B ENEFI TS FOR PAT I E N T S W HE N C O MPAR E D TO O P E N S UR G E R Y, INCLUDI NG SH ORTER H OSP I TAL STAY, R E D UC E D MO R BI D I T Y AN D BE T T E R CLIN I C AL OU TC OMES I N TH E S HO R T T E R M, A N E W ST UDY HAS I D E N T I F I E D . 1
Dalhousie University, Halifax, Nova Scotia
In brief, results from the multicentre (non randomized) Canadian study have been impressive, with arthroscopic ankle fusion resulting in better AOS scores in short term (at one or two years), and shorter hospital stays – while offering equivalent deformity correction, clinical outcomes and rate of nonunion.1
The minimally-invasive nature of arthroscopic ankle fusion for the patient is the main benefit that Dr Glazebrook is keen to hammer home. “One of the biggest complications you get from open surgeries is problems with wound healing, and the incidence you see with arthroscopic procedures is much lower,” he said. “You don’t have to do a large incision, so it is better for people who have poor healing ability, and the patients recover more quickly, have less pain and lower morbidity.”
Dr Mark Glazebrook Orthopaedic surgeon
ince its inception, the use of arthroscopy for ankle fusion procedures has gained increasing popularity, but there is still some reluctance to use the technique in place of open surgery, partly due to a lack of published clinical studies comparing both techniques.1 “In general, for ankle fusions across the whole country, I think you would find that arthroscopy use is low, but it is growing,” commented Mark Glazebrook (Dalhousie University, Halifax, Nova Scotia), an orthopaedic surgeon who is co-investigator in the new study exploring the outcomes from both surgical approaches.
“One of the biggest complications you get from open surgeries is problems with wound healing, and the incidence you see with arthroscopic procedures is much lower.” – Mark Glazebrook
Dr Glazebrook went on to note that one of the possible explanations for the limited use of arthroscopic ankle fusion could be the perceived complexity. Specifically, not only is the procedure typically longer than open surgery (approximately 1.5 hours versus 1 hour), it is more technically demanding for both surgeons and nurses during the initial learning curve period. But perhaps the most pertinent barrier is the belief held by some that the ankle is difficult to scope. “It really isn’t,” said Dr Glazebrook. “Yes, there is a learning curve, and technical skill is required, but once achieved, the benefits are there for the patient. Currently there are many courses that are now available that can teach the technique.” Indeed, Dr Glazebrook suggested that centres who rely on open surgery should not be afraid to try arthroscopic ankle fusion techniques, because if an arthroscopic operation is not going well the surgeon can always revert to an open approach. He added that this is particularly useful in cases where there significant deformity of the ankle is found, as open surgery is more suitable in that setting.
“The advancement of all orthopaedic surgery has been the progression to a minimallyinvasive approach, and the same applies to ankle fusion.” – Mark Glazebrook
With these considerations in mind, and the data from the comparative study now published, Dr Glazebrook offered his predictions as to what place arthroscopic ankle fusion will have in the future. “The advancement of all orthopaedic surgery in general has been the progression to a minimally-invasive approach, and the same applies to ankle fusion,” he said. “All it takes is for patients to become aware that there is a better way of doing the operation, and they will start demanding it. And then surgeons will be either willing, or compelled, to do it.
“In addition, if you’re doing an operation arthroscopically, and the outcomes are better, I think the healthcare system is going to want to support that, and therefore one could envisage the potential for increased remuneration.” He concluded: “If you’re not considering using this technique I think you are missing the boat.”«
1. Townshend D, Di Silvestro M, Krause F et al. Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series. JBone Joint Surg Am. 2013;95:98-102
Technique Tip: When compared to open surgeries, arthroscopic ankle fusions are more forgiving in terms of congruency, as they do not require extensive tissue stripping. However, for optimum congruency, be sure to shave off the medial and lateral sides of the talar dome.
COMM U N I T Y & I N I T I AT I V E S
Team work and surgical intervention changes lives in developing countries
M A N Y PEOPL E I N UNDERDEV ELO P E D C O UN T R I E S E N D UR E I MP OV E R I S HE D L I V ES, S IM P LY B EC AUSE TH EY DO NOT HAV E AC C E S S TO T HE K I N D S O F V I TAL S UR G I CA L P R OCE DU RES C OMMON I N TH E D E V E LO P E D W O R L D . S O UT H AME R I C A HAS A HIGH INC I DENC E OF H I P DYSPL AS I A, D UE TO T HE G E N E T I C MAK E -UP O F T HEI R P OP UL ATI ON AND, I N SOME CAS E S , D UE TO C ULT UR AL P R AC T I C E S . 1 ME D I C A L M ISSIO NS PROV I DE A UNI QU E O P P O R T UN I T Y FO R ME D I C AL P E R S O N N E L US I N G STATE OF TH E ART MEDI C AL D E V I C E S TO C O R R EC T T HE S E D I S ABI L I T I E S , IM P R OV I NG TH E QU AL I T Y OF PEO P L E ’S L I V E S AN D AL LO W I N G T HE M TO E N T E R T HE W O R K FO R C E .
COMM U N I T Y & I N I T I AT I V E S
“ T his is about an organization with a lot of parts, and each on e of those parts is doing a worthy job. The contribution made by each participant is equally crucial .” – Marc J. Moreau
“We enjoy a fantastic lifestyle here in Canada; we need people who can take a bit of time out of their lives to go and give help,” commented Marc J. Moreau, an ortho paedic surgeon at the University of Alberta. “It’s also a very enjoyable experience – there is a sense of adventure.” He and his wife Barbara have made 15 missions to Ecuador, the last 13 being with the Canadian Association of Medical Teams Abroad (CAMTA), an organization they co-founded. Mrs. Moreau is the Chief Organizer, while Dr Moreau performs pediatric surgeries, and all five of their children – and their two son-in-laws – have participated over the years. “This is about an organization with a lot of parts, and each one of those parts is doing a worthy job,” Dr Moreau emphasized. “The contribution made by each participant is equally crucial.” The importance of a team effort was also underscored by Robert B. Bourne, a retired orthopaedic surgeon and professor emeritus at Western University, London, Ontario, who, alongside Cecil Rorabeck, organized Operation Walk Canada to conduct annual medical missions to Guatemala and Ecuador. The team is comprised of volunteers from Canada, the US, the UK, Spain and Australia, and have just completed their 14th mission. “It’s like a Mash Unit,” said Dr Bourne, “you require the talents of everyone to make this operation work. We don’t have the luxury of bringing extra sets of implants and instruments, so the volunteers who clean and sterilize our instruments are crucial – every bit as important as the surgical team.”
Every year Operation Walk Canada takes a team of about 55 to Guatemala and a team of 37 to Ecuador. Seven to nine days are spent in each country; patients are seen on day one, followed by four days of surgeries. The remaining time is devoted to overseeing each patient’s recovery prior to transfer to local healthcare volunteers. During their annual sojourns in Guatemala and Ecuador, the Operation Walk team completes about 100 hip and knee replacements. “We were asked to go to Ecuador to solve a particular problem, namely secondary hip arthritis due to developmental dysplasia of the hip (DDH),” said Dr Bourne. In Ecuador, many women swaddle their babies on their backs when they return to work soon after giving birth. This causes forced extension of the infant’s hips and contributes to the development of DDH. “It’s tragic,” Dr Bourne continued, “as nearly all the patients we see are young women. They are in severe pain, on crutches, with markedly unequal leg lengths, and with no jobs or husbands. It’s quite dramatic.” Operation Walk works with local healthcare providers who select poor patients who would otherwise have no access to mobility-restoring total hip and knee replacements. “We organize one year in advance, and apply to Smith & Nephew for the implants,” said Dr Bourne. “They give us their state of the art, premium implants, as our patients are generally young, and need implants that will last a long time, preventing the need for revision surgery.”
COMM U N I T Y & I N I T I AT I V E S
“[Smith & Nephew] give us their state of the art, premium implants, as our patients are gen erally young, and n eed implants that will last a long time, preventing the n eed for revision surgery.” – Robert B. Bourne
CAMTA provides about 45 to 50 surgeries per trip to Ecuador, mostly hip reconstruction and replacement in adults that are done by reconstructive hip surgeons Drs. Edward Masson, Paul Moreau, Paul Leung, Rejean Cloutier and Don Weber to name a few. Dr Moreau performs procedures on around thirty children per trip to correct hip dysplasia, congenital clubfeet and other conditions. Each mission comprises around 100 people plus supplies. “We accumulated some supplies that we can leave in a bodega down there, but we bring down most of the supplies,” said Dr Moreau. “We work in twos to reduce the stress, and to have backups – people get sick and this can reduce the team down to a skeleton crew.” CAMTA also delivered a SIGN intramedullary nail system to local hospitals for trauma cases. “Patients suffering broken bones in highway or farm accidents can now be treated with intramedullary nails at rural hospitals, and be back on their feet within 48 hours, instead of having to travel to a larger centre where marginal treatment may be all that is offered to those who can’t afford proper care,” explained Dr Moreau.
Dr Bourne recounted a story of a 38-year-old male patient who stood just five feet tall, with skeletal dysplasia that led to crippling bilateral hip arthritis that was so severe the patient could no longer stand-up. While his hips were being replaced, a volunteer got to know the family, especially one son who obviously had the same skeletal dysplasia as his father. The child had also lost the vision in one eye from a soccer injury. As Operation Walk was aware of the impending arrival of another medical mission of eye surgeons from South Carolina, USA, who were coming to the same hospital in Guatemala two months later, it was organized for the child to have sight-restoring eye surgery. “This highlights the high level of cooperation among many wonderful aid-giving groups,” said Dr Bourne. «
Like Operation Walk, each CAMTA volunteer raises their own expenses, which they accomplish by a wide range of activities that often provide additional funds for the effort. “We used to have to raise about $100,000 to buy prostheses, but when Smith & Nephew stepped up to the plate by donating implants, they made a huge difference to our program,” said Dr Moreau.
1. Loder RT, Skopelja EN. The Epidemiology and Demographics of Hip Dysplasia ISRN Orthopedics. 2011;238607:46-57.
Dr Robert B. Bourne
Providing Total Joint Replacement Surgery to Those in Need
Colophon Healthshare Magazine is a publication by Smith & Nephew Canada and is selectively distributed to healthcare professionals. The goal of Healthshare Magazine is to share interesting information in the field of orthopaedics, endoscopy, sports medicine, trauma and other healthcare related information with a professional audience.
2280 Argentia Road Mississauga, ON L5N 6H8 Canada Telephone: +1 (915) 813 77 70 www.smith-nephew.com/canada/ Project Team Tim Bourne, Kim Auty, Melissa Donnelly
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Operation Walk Canada Inc.
firstname.lastname@example.org Telephone: 905 813 6510 Cell phone: 416 709 0384 Fax: 905 813 7775
Our purpose, as a volunteer medical service organization,is to provide total joint replacement surgery to patients who live in developing countries and who have no access to professional medical care for their debilitating bone and joint diseases, the most common of which is osteoarthritis. Missions began in Guatemala in 2006 and in Ecuador in 2009. Since then, our volunteer medical teams have helped hundreds of patients regain their mobility... one and many times, two joints at a time.
Your Donation Matters
Operation Walk Canada Inc. is a registered not-for-profi t charity and all donations are income tax receiptable. Our work relies entirely on the generosity of our private and corporate donors with 100% of all funds raised going to each of our missions.
Limmatstrasse 107 8005 Zurich Switzerland Telephone: +41 43 508 03 13 email@example.com www.medicalwriters.com
Project Director Wesley Portegies, MBA Cell phone: +41 79 651 37 95 firstname.lastname@example.org Authors Peter Stevenson, PhD Liam Davenport
To make a donation and learn more about our organization please take a moment to visit our website:
Graphic Designer Patrick van Gerwen Photography Julie Heather Photography Roberto Lazo Vadim Daniel Printing & Distribution Hemlock Printers Ltd. 7050 Buller Avenue Burnaby, BC. V5J 4S4 Canada.
ÂŠ 2014 by Smith & Nephew Canada, 2280 Argentia Road, Mississauga, ON L5N 6H8, Canada. All rights reserved. No part of this publication may be reproduced in any manner without permission. Every effort has been made to contact copyright holders and to ensure that all the information presented is correct. Some of the facts in this volume may be subject to debate or dispute. If proper copyright acknowledgment has not been made, or for clarifications and corrections, please contact the publishers and we will correct the information in future reprintings, if any.
Supporting healthcare professionals for over 150 years
Published on Nov 17, 2014
Published on Nov 17, 2014
Healthshare Magazine serves as a platform for the exhibition of technologies, cutting edge practices and expert case reports from the whole...