Arthroplasty: Present practices by DR. D. P. SWAMI DR. D. P. SWAMI
COMPARISON OF DIFFERENT APPROACHES FOR HIP REPLACEMENT, DIFFERENT ASPECTS OF OVERLAPPING SURGERIES IN TKR AND TEST FOR CONTAMINATION IN OPERATION THEATER
Superior Capsular Reconstruction Outcomes Wrightington 2020Lennard Funk
Hariharan Mohan, Jagwant Singh, Michael Walton, Lennard Funk, Puneet Monga
Cautious optimism following SCR may be offered to this challenging subset of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery. Further studies with longer term followup are recommended.
Arthroplasty: Present practices by DR. D. P. SWAMI DR. D. P. SWAMI
COMPARISON OF DIFFERENT APPROACHES FOR HIP REPLACEMENT, DIFFERENT ASPECTS OF OVERLAPPING SURGERIES IN TKR AND TEST FOR CONTAMINATION IN OPERATION THEATER
Superior Capsular Reconstruction Outcomes Wrightington 2020Lennard Funk
Hariharan Mohan, Jagwant Singh, Michael Walton, Lennard Funk, Puneet Monga
Cautious optimism following SCR may be offered to this challenging subset of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery. Further studies with longer term followup are recommended.
Early Outcome of Discectomy with Interspinous Process Distraction Device a Re...CrimsonPublishersOPROJ
Early Outcome of Discectomy with Interspinous Process Distraction Device a Retrospective Cross-Sectional Study by Gunaseelan Ponnusamy* in Crimson Publishers: Orthopedic Research and Reviews Journal
Presentation delivered at 2020 AAOS annual meeting by Dr Adnan Saithna, Professor of Orthopedic Surgery, Overland Park, Kansas. This randomised controlled study demonstrates that combined ACL and anterolateral ligament reconstruction is not associated with an increased risk of adverse events when compared to isolated ACL reconstruction
A prospective observational study on comparing the outcome of patellar resurf...Dr.Avinash Rao Gundavarapu
Introduction: Total Knee Arthroplasty (TKA) has been a very successful surgery in relieving pain and restoring function in osteoarthritis. Conflicting evidence in literature exists regarding the merits of patellar resurfacing during TKA over non-resurfacing. Our aim is to evaluate and compare the difference between patellar resurfaced group and non-resurfaced group in primary TKA.
Materials and Methods: This prospective obsevational study was initiated in May 2016 conducted till April 2008 (2 years) in Yashoda Superspeciality Hospital, Hyderabad. At least 14 mm of patella was ensured to be retained after patellar cut. A total of 40 patients were allocated to receive (n=20) or not to receive patellar resurfacing (n=20) during primary TKA. The data was analyzed statistically using the Student t test. Overall patient satisfaction was recorded using the SF-36 score.
Results: Of the 40 patients, 67.5% females and 32.5 % males underwent TKA. Among those who underwent resurfacement, 40% were males. 75% among the non-resurfaced group were females. Right knee was operated on 37.5% of cases. Mean operative time being 103.9 and 122.5 minutes in nonresurfaced and resurfaced cases respectively. Mean patellar thickness was 22.1mm in nonresurfaced and 23.6mm in resurfaced group. The difference in VAS score, modified HSS score, KSS scores between the two groups were statistically insignificant with p-values of 0.230, 0.0214, 0.2513 respectively at the end of two year,
but there was significant reduction of anterior knee pain in the resurfaced with p-value < 0> Conclusion: The functional outcome was not affected by whether the patella was resurfaced or nonresurfaced. There was no significant difference between the two groups with respect to the prevalence of knee-related readmission, or of subsequent patella-related surgery or patients overall satisfaction. We recommend selective patellar resurfacing at the time of primary total knee replacement.
Keywords: TKA, Patellar resurfacement, Non-resurfacement, HSS score, KSS score.
Early Outcome of Discectomy with Interspinous Process Distraction Device a Re...CrimsonPublishersOPROJ
Early Outcome of Discectomy with Interspinous Process Distraction Device a Retrospective Cross-Sectional Study by Gunaseelan Ponnusamy* in Crimson Publishers: Orthopedic Research and Reviews Journal
Presentation delivered at 2020 AAOS annual meeting by Dr Adnan Saithna, Professor of Orthopedic Surgery, Overland Park, Kansas. This randomised controlled study demonstrates that combined ACL and anterolateral ligament reconstruction is not associated with an increased risk of adverse events when compared to isolated ACL reconstruction
A prospective observational study on comparing the outcome of patellar resurf...Dr.Avinash Rao Gundavarapu
Introduction: Total Knee Arthroplasty (TKA) has been a very successful surgery in relieving pain and restoring function in osteoarthritis. Conflicting evidence in literature exists regarding the merits of patellar resurfacing during TKA over non-resurfacing. Our aim is to evaluate and compare the difference between patellar resurfaced group and non-resurfaced group in primary TKA.
Materials and Methods: This prospective obsevational study was initiated in May 2016 conducted till April 2008 (2 years) in Yashoda Superspeciality Hospital, Hyderabad. At least 14 mm of patella was ensured to be retained after patellar cut. A total of 40 patients were allocated to receive (n=20) or not to receive patellar resurfacing (n=20) during primary TKA. The data was analyzed statistically using the Student t test. Overall patient satisfaction was recorded using the SF-36 score.
Results: Of the 40 patients, 67.5% females and 32.5 % males underwent TKA. Among those who underwent resurfacement, 40% were males. 75% among the non-resurfaced group were females. Right knee was operated on 37.5% of cases. Mean operative time being 103.9 and 122.5 minutes in nonresurfaced and resurfaced cases respectively. Mean patellar thickness was 22.1mm in nonresurfaced and 23.6mm in resurfaced group. The difference in VAS score, modified HSS score, KSS scores between the two groups were statistically insignificant with p-values of 0.230, 0.0214, 0.2513 respectively at the end of two year,
but there was significant reduction of anterior knee pain in the resurfaced with p-value < 0> Conclusion: The functional outcome was not affected by whether the patella was resurfaced or nonresurfaced. There was no significant difference between the two groups with respect to the prevalence of knee-related readmission, or of subsequent patella-related surgery or patients overall satisfaction. We recommend selective patellar resurfacing at the time of primary total knee replacement.
Keywords: TKA, Patellar resurfacement, Non-resurfacement, HSS score, KSS score.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
G112 Ito & Shiromaru (2009). Patients’ coping strategies before and after ab...Takehiko Ito
G112 Ito & Shiromaru (2009). Patients’ coping strategies before and after abdominal surgery: A questionnaire survey. The 1st International Nursing Research Conference of World Academy of Nursing Science, Kobe: Program & Abstracts, 235.
Role of 3D printing & 3D model in Complex Total Hip Replacement Queen Mary Hospital
Role of 3D printing & 3D model in Complex Total Hip Replacement
Dr. Kalaivanan Kanniyan
for queries - drkkbriyan@gmail.com / drkkbriyan@outlook.com
Asian Joint Reconstruction Institute
AJRI
chennai
India
Tamil nadu
complex hip replacement , knee replacment, knee navigation
Fungal Periprosthetic Joint Infection By Candida Glabrata – Two Stage Revisio...Queen Mary Hospital
Fungal Periprosthetic Joint Infection By Candida Glabrata – Two Stage Revision Is A Good Option.
Dr. Suryanarayan Pitchai, Dr. Kalaivanan Kanniyan , Dr. P. Ashok Kumar, Dr. Y. Subramanyam
Asian Joint Reconstruction Institute (AJRI), SIMS Hospitals, Chennai 600026, Tamil Nadu, India.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pro disc l replacement vs circumferential arthrodesis of spine
1. Prospective, Randomized, Multicenter Food and Drug
Administration Investigational Device Exemption Study of the
ProDisc -L Total Disc Replacement Compared with
Circumferential Arthrodesis for the Treatment of Two-Level
Lumbar Degenerative Disc Disease: Results at 24 months.
ProDisc -L
Total Disc Replacement
Circumferential
Arthrodesis
Level of Evidence: Therapeutic Level I
2. Performed by :
• Rick Delamarter, MD The Spine Institute at Saint John's Health Center,
1301 20th Street, Suite 400, Santa Monica, CA 90404
•
Jack E. Zigler, MD Texas Back Institute/Texas Health Research Institute,
6020 West Parker Road, Suite 200, Plano, TX 75093
•
Richard A. Balderston, MD Pennsylvania Hospital, 800 Spruce Street, 1st
Floor, 3B, Philadelphia, PA 19107
•
Frank P. Cammisa, MD Hospital for Special Surgery, 523 East 72nd Street,
New York, NY 10021
•
Jeffrey A. Goldstein, MD and Jeffrey M. Spivak, MD Hospital for Joint
Diseases Spine Center, 301 East 17th Street, New York, NY 10038
3. Presented in :
• The Journal of Bone & Joint Surgery. 2011; 93:705715 doi:10.2106/JBJS.I.00680
4. Degenerative Disc Disorder
-
Low Back Ache
A major public health problem
The leading cause of disability for people < 45
2nd leading cause for physician visits
3rd most common cause for surgical procedures
5th most common reason for hospitalizations
Lifetime prevalence: 49%–80%
Pai et al. 2004, Orthop Clin N Am
5. AIM
Arthrodesis / Spinal fusion had become a
standard surgical procedure , a more
predictable and reproducible.
symptomatic degenerative disease,
degenerative spondylolisthesis,
degenerative lumbar scoliosis, postdiscectomy-syndromes or segmental
instability adjacent to a previous fusion.
Arthrodesis alters the biomechanics of
the spine , loss of motion and overall
shift in the sagittal alingment
Induces degenerative changes in the
nearby spinal motion segments.
6. Total Disc Replacement
• Disc removal , assuming it to be the main source of pain
• Restoration of disc height (increase the foraminal diameter, relieve
loads across the facet joints and improve the pattern of load
bearing between vertebrae)
•
Segmental stability
• Preservation or improvement of segmental motion
• Lordosis curve (rebalance the spine - preserves the motion,
protect adjacent segment from accelerated degeneration.)
• Limit Disability & early return to work.
Total lumbar disc replacement, H. M. Mayer, MD, PhD, Orthopaedic Surgeon,
Neurosurgeon, Associate Professor, 2005, JBJS
7. TDA > Arthodesis
•
•
•
•
•
•
•
•
•
Guyer RD et al 2009 Delamarter R et al 2008 *
Cunningham BW et al 2008’
Siepe CJ et al 2007
Zigler J et al 2007 *
Panjabi et al 2007 *
Panjabi et al 2007’
Blumenthal S et al 2005*
Bertagnoli R et al 2005 *
•
The purpose of this study is to determine clinical results of
Pro Disc L Total Disc Replacement as compared with
Circumferential Spinal fusion for the treatment of degenerative
disease at two contagious vertebral levels from L3 to S1.
8. MATERIAL & METHOD
• From January 2002 to June 2004, a total of 256 patients were randomized
by 38 spine surgeons at 16 sites across the United States.
• Blocked randomization was performed in a controlled design
• with use of a 2:1 ratio of total disc arthroplasty to circumferential
arthrodesis
• Overall, 237 patients (165 in the total disc replacement group & 72 in the
arthrodesis group) were treated.
• At the end of the study of 24 months a total of 203 patients (including
143 in the total disc replacement group and 60 in the arthrodesis group
were available.
10. STUDY DESIGN
Inclusion criteria
• With degenrative disc disease at
two levels from L3 to S1.
• Patients who had minimum of 6
months of unsuccessful
nonoperative treatment
• +/- Leg pain
• With a minimum Oswestry
Disability Index ODI score of
>_ 40
Exclusion criteria
• spondylolisthesis >grade I,
• degenerative disc disease at
more than two levels,
• previous arthrodesis
• inability to comply with the
study protocol.
11. Degenerative Disc Disease includes
• Lumbar spine instability,
• loss of intervertebral disc height,
• scarring of the annulus fibrosus,
• herniated nucleus pulposus,
• vaccum phenomenon of disc
INVESTIGATION MODES :
•
•
•
•
•
Flexion-extension Radiographs,
Computed Tomography (CT),
Magnetic Resonance Imaging (MRI),
Discography,
Myelography
12. STUDY PATTERN
• Study approval was obtained from each site's institutional review board
prior to the start of the study. Patient randomization was performed with
use of a 2:1 ratio of TDR to circumferential arthrodesis.
• Patients in the investigational group were managed with TDR at both
levels.
• The control group was managed with a two-level anterior lumbar
interbody arthrodesis with use of a commercially available femoral ring
allograft and posterolateral arthrodesis with autogenous iliac crest bone
graft in combination with pedicle screw instrumentation.
14. ProDisc-L Device Description
• a semi-constrained design
based on the ball-and-socket
principle
• consists of 2 End Plates
manufactured from cobaltchromium-molybdenum
(CoCrMo) alloy and a convex
ultra-high molecular weight
polyethylene (UHMWPE)
insert.
• Fixation is provided by a
central keel and titanium
plasma spray coating on each
end plate.
• Bone ingrowth
19. Pro Disc L allowing movement during flexion and extension
20. SURGICAL METHOD
The surgical technique of
performing the two-level lumbar
arthroplasty is similar to that of a
single-level lumbar arthroplasty
• The entire disc is removed
from an anterior approach .
• The disc space is distracted.
• The TDR device is inserted.
Lumbar Total Disc Replacement, Surgical Techniques ,Patrick Tropiano, MD; Russel C.
Huang, MD; Federico P. Girardi, MD; Frank P. CammisaJr., MD; Thierry Marnay, MD
, March 01, 2006, JBJS (Am)
21. Lumbar Total Disc Replacement, Surgical Techniques ,Patrick Tropiano, MD; Russel C.
Huang, MD; Federico P. Girardi, MD; Frank P. CammisaJr., MD; Thierry Marnay, MD
, March 01, 2006, JBJS (Am)
22. Lumbar Total Disc Replacement, Surgical Techniques ,Patrick Tropiano, MD; Russel C.
Huang, MD; Federico P. Girardi, MD; Frank P. CammisaJr., MD; Thierry Marnay, MD
, March 01, 2006, JBJS (Am)
23. PRE OPERATIVE DEMOGRAPHIC DATA
• *Continuous variables were analyzed with the Wilcoxon rank-sum test,
and categorical variables were analyzed with the Fisher exact test.
†The values are given as the mean and the standard deviation.
‡Data were unavailable for one patient in the total disc replacement
group.
§Patients may be included in more than one category.
#Previous conservative treatment other than medication.
24. Demographic characteristics
Total Disc
Replacement
(N = 165)
Arthrodesis
(N= 72)
Sex No. of patients
P Value *
0.6701
Male
95
39
Female
70
33
Age (yrs)
41.8+_ 7.73
41.8 +- 7.81
0.9745
Body mass Index (kg/m2)
27+-4.52
27.1+_4.05
0.8723
Smoking status
0.1373
Never
86
29
Former
31
21
Current
47
22
25. Demographic characteristics
Total Disc
Replacement
(N = 165)
Arthrodesis
(N= 72)
Previous surgical treatment
P Value *
0.8864
None
96
43
Any
69
29
Discectomy
32
13
Intradiscal electrothermic theraphy
17
7
Laminectomy
31
9
Laminotomy
4
2
other
12
8
26. Demographic characteristics
Total Disc Replacement
(N = 165)
Arthrodesis
(N= 72)
Previous conservative treatment
P Value*
0.9436
injection
127
52
Physical therapy
135
61
Corset/Brace
68
28
chiropractic
60
28
other
35
12
Duration of pain in the Back / leg
0.6145
< 6 months
1
0
6 months to 1 year
16
4
> 1 year
148
68
27. Statistical methods
• For the purpose of FDA evaluation, a composite, binary end
point consisting of ten criteria was estabilished for each
treatment group.
• At the end of 24 months , the pateint had to meet all the 10
criteria for to be labelled as a successive or statistical failure
28. Components of Composite End Point at 24 Months
1. >_ 15% improvement in ODI compared with baseline
2. Improvement in SF-36 PCS compared with baseline
3. Neurological status improved or maintained from baseline
4. No secondary surgical procedures to remove or modify the total disc
replacement implant or arthrodesis implant/site
Radiographic success
5. No subsidence >3 mm
6. No migration >3 mm
7. No radiolucency/loosening
8. No loss of disc height >3 mm
Motion status
9. Total disc replacement: range of motion improved or maintained
from baseline
10.Arthrodesis: no motion (<10° angulation, total for two levels
combined) on flexion and extension radiographs
*ODI = Oswestry Disability Index; SF-36 PCS = Short Form-36 physical component score.
30. Intraoperative data showed that the TDR group had
•significantly decreased operative times (p < 0.0001),
•estimated blood loss (p = 0.0013), and
•length of hospital stay (p < 0.0001)
Intraoperative Data
Total Disc
Replacement
(N = 165)
Arthrodesis
(N= 72)
Implant level
P Value*
1.0000
L3 – L5
14
8
L4- L5
151
64
Operative time in min
160.2 +_ 73.30
272.8+_ 81.68
< 0.0001
Estimated blood loss in ml
398.1+_451.48
569.3 +- 466.63
0.0013
Length of hospital stay in days
3.8+_ 1.53
5+_1.93
<0.0001
*Continuous variables were analyzed with the Wilcoxon rank-sum test, and categorical variables were analyzed with the Fisher
exact test.
†The values are given as the mean and the standard deviation.
‡Data were unavailable for three patients in the total disc replacement group.
31. Clinical Outcome Measurements
• patient was clinically evaluated preoperatively, at 6 weeks postoperatively,
and at 3,6,12,18,24 months postoperatively.
• Every visit included physical and neurological examinations, radiographic
evaluation, determination of medication use, work and recreation status,
and completion of self-assessment questionnaires (including the ODI,
Short Form of the Medical Outcomes Study [SF-36], and visual analog
scales [VAS] for pain and satisfaction.
• Physical and neurological examinations were performed to assess nerve
root tension, reflexes, muscle strength, and sensory deficits. Radiographic
evaluation consisted of neutral anteroposterior and lateral views, flexionextension views, and lateral bending views.
32. Clinical Outcomes: Primary
• At twenty-four months, eighty-seven (58.8%) of 148 patients
in the total disc replacement group and thirty-two (47.8%) of
sixty-seven patients in the arthrodesis group met all ten
criteria and were considered a study succes
• non-inferiority was demonstrated between the two groups
with use of a Blackwelder hypothesis with ? = 0.125 (p =
0.0008).
• The difference between the two treatments was not
significant (p = 0.0874).
33. Oswestry Disability Index (ODI)
• The ODI low back pain disability questionnaire is a validated method of
assessing a patient's level of pain and functional disability.
• Baseline preoperative ODI values were similar for both treatment groups
(64.7 points for the TDR group, compared with 64.8 points for the
arthrodesis group)
• In both groups, patients showed significant improvement in ODI scores
from baseline at all follow-up periods (p < 0.0001).
• The total disc replacement group demonstrated significantly greater
improvement than the arthrodesis group did at all follow-up time points
(p = 0.0474).
• At twenty-four months, the mean improvement from baseline
was 52.4% in the total disc replacement group compared with
40.9% in the arthrodesis group (p = 0.0282).
34. Oswestry Disability Index Scores
Oswestry Disability Index
Score*(points)
Percentage Change from
Baseline*(%)
Time Point
Total Disc
Replacement
Arthrodesis Total Disc
Replacement
Arthrodesis P Value*
Baseline
64.7 ± 11.4
64.8 ± 9.5
-
-
-
6 wks
43.8 ± 18.2
50.8 ± 17.8
30.8 ± 28.9
22.2 ± 27.2
0.0228
3 months
38.1 ± 20.7
44.4 ± 15.7
40.5 ± 32.3
30.9 ± 24.6
0.0445
6 months
35.1 ± 21.9
43.9 ± 17.1
45.3 ± 34.6
32.3 ± 26.7
0.0068
12 months
33.7 ± 23.9
41.1 ± 23.0
48.0 ± 36.4
37.9 ± 34.7
0.0474
18 months
32.8 ± 24.7
42.3 ± 22.5
49.3 ± 37.9
36.1 ± 33.8
0.0215
24 months
30.3 ± 24.3
38.7 ± 24.1
52.4 ± 38.1
40.9 ± 36.0
0.0282
*The values are given as the mean and the standard deviation.
†The Wilcoxon rank-sum test was used to compare total disc replacement and
arthrodesis with regard to the percentage change from baseline.
35. OSWESTRY DISABILITY INDEX - ODI
•
•
•
•
•
•
•
•
•
•
Pain intensity
Personal care
Lifting
Walking
Sitting
Standing
Sleeping
Sex life
Social life
Travelling
• 0 to 20 % Minimal
disability
• 21 to 40 % Moderate
disability
• 41 to 60 % Severe
disability
• 61 to 80% crippled
• 81 to 100 % Bed bound
36. SF-36 Physical Component Score
• Baseline preoperative values for the SF-36 physical component score (PCS)
were similar for both treatment groups (29.5 points for the total disc
replacement group, compared with 30.1 points for the arthrodesis group)
• Both treatment groups showed significant improvement at all follow-up
time-points in comparison with baseline (p < 0.0279).
• The total disc replacement group showed significant improvement
compared with the arthrodesis group at six weeks and at three, six, and
twenty-four months (p = 0.0379, p = 0.0044, p = 0.0068, and p = 0.0141,
respectively).
• At twenty-four months, the score for the total disc
replacement group improved to a mean of 43.9 points and
the score for the arthrodesis group improved to a mean of
39.2 points.
37. Short Form-36 Physical Component Scores
Short Form-36 Physical
Component Score*(points)
Percentage Change from
Baseline*(%)
Time Point
Total Disc
Arthrodesis
Replacement
Total Disc
Arthrodesis
Replacement
P Value†
Baseline
29.5 ± 5.4
30.1 ± 6.7
—
—
—
6 weeks
34.8 ± 7.7
31.9 ± 6.9
21.4 ± 33.4
12.2 ± 32.2
0.0379
3 months
38.7 ± 9.4
34.7 ± 7.3
34.9 ± 38.2
20.7 ± 37.7
0.0044
6 months
41.2 ± 10.3
37.0 ± 9.1
43.8 ± 45.6
30.1 ± 48.3
0.0068
12 months
42.4 ± 11.2
39.3 ± 9.9
48.8 ± 51.6
38.3 ± 47.0
0.1108
18 months
42.7 ± 11.5
38.1 ± 10.7
51.4 ± 55.6
37.7 ± 52.0
0.0899
24 months
43.9 ± 11.9
39.2 ± 11.2
54.2 ± 54.6
36.2 ± 44.9
0.0141
*The values are given as the mean and the standard deviation.
†The Wilcoxon rank-sum test was used to compare the total disc replacement and
arthrodesis groups with regard to the percentage change from baseline.
38. Neurological Success
• Neurological success was defined as the maintenance or improvement of
patient responses to all neurological criteria, including motor status,
sensory status, reflexes, and a straight leg raise test
• At six months, the percentage of patients with neurological success was
significantly higher in the TDR group (87.3%; 131 of 150) than in the
arthrodesis group (71.6%; forty-eight of sixty-seven) (p = 0.0068).
• At twenty-four months, the percentage remained higher in
the total disc replacement group (89.2%; 132 of 148) than in
the arthrodesis group (80.6%, fifty of sixty-two), but this small
difference was not significant.
• The Fisher exact test (two-sided) was used to compare the total disc
replacement and arthrodesis groups.
40. Secondary Surgical Procedures
• Overall, four (2.4%) of 165 patients in the total disc replacement group
and six (8.3%) of seventy-two patients in the arthrodesis group required a
secondary surgical procedure at the index level or levels.
• This fourfold difference in the rate of secondary surgery for the
arthrodesis group was significant (p = 0.0465).
• The average number of days from the index procedure to secondary
surgery was 567.7 (range, 480 to 736) in the total disc replacement group
and 255.5 (range, twenty-one to 560) in the arthrodesis group.
41. SECONDARY SURGICAL PROCEDURES
• One patient (0.6%) in the total disc replacement group had anterior
migration of the superior arthroplasty implant and underwent revision
arthrodesis at that level.
• The remaining 3 patients (1.8%) in the TDR group underwent a secondary
surgical procedure (foraminotomy and/or facetectomy) for posterior
decompression; 2 these patients underwent a one-level decompression,
and one patient underwent a decompression at both levels.
• Of the 6 patients who underwent a secondary surgical procedure in the
arthrodesis group, 5 had spinal implant removal because of ongoing pain
and one had implant removal, decompression (bilateral medial
facetectomy and hemilaminectomy), and revision of the bone fusion sites
because of a pseudarthrosis at L5-S1.
42. Radiographic Outcomes
• The radiographic outcomes that were assessed included
• device migration ( 1 anterior migration of the superior arthroplasty
implant)
• device subsidence(3 patients in TDR of > 3 mm-clinically insignificant),
• disc height,
• radiolucency around the implant,
• Fusion status in the arthrodesis group
• Flexion-Extension range of motion in the TDR group averaged
7.8° ± 5.3° at the level of the superior disc
6.2° ± 4.1° at the level of the inferior disc
43. Lateral views of Lumbar spineof a 38 yr old treated with ProDisc L Total Disc
Replacement at L3 -4 and L4-5 level made at end of 24 month followup .
X Rays are taken in Neutral , Flexion and in Extension of lumbar spine.
44. Clinical Outcomes: Secondary
Visual Analog Scale for Pain
• For both groups, the VAS pain assessment showed significant
improvement from preoperative levels at all time points postoperatively
(p < 0.0001)
• At twenty-four months, the mean VAS score demonstrated a 43.3-mm
mean reduction from baseline for the total disc replacement group
compared with a 36.7-mm mean reduction for the arthrodesis group.
• A significant difference between the treatment groups was observed only
at the eighteen-month follow-up (p = 0.0248).
45. Visual Analog Pain Scores
Visual Analog Pain Score*
Change from Baseline*
Time Point
Total Disc
Arthrodesis
Replacement
Total Disc
Arthrodesis
Replacement
P Value†
Baseline
75.7 ± 16.0
74.7 ± 13.6
—
—
—
6 weeks
41.5 ± 25.4
46.5 ± 24.9
34.5 ± 28.6
28.7 ± 28.4
0.1437
3 months
38.9 ± 27.6
42.1 ± 23.4
36.7 ± 28.5
32.3 ± 26.0
0.3170
6 months
37.9 ± 27.5
44.3 ± 26.0
38.1 ± 29.6
30.4 ± 28.6
0.0715
12 months
35.6 ± 28.5
40.3 ± 27.9
40.4 ± 29.4
34.9 ± 28.5
0.2527
18 months
35.2 ± 29.8
45.6 ± 30.3
40.3 ± 31.9
28.7 ± 31.0
0.0248
24 months
31.9 ± 30.5
38.4 ± 29.8
43.3 ± 33.3
36.7 ± 30.3
0.1177
*The values are given as the mean and the standard deviation.
†The Wilcoxon rank-sum test was used to compare the total disc replacement and
arthrodesis groups.
46. Visual Analog Scale for Patient Satisfaction and Willingness to Undergo
Surgery Again
• At twenty-four months, the mean score was 77.7 mm for the total disc
replacement group compared with 68.9 mm for the arthrodesis group
(p = 0.0126).
• Patients were asked whether they would have the same surgical
treatment again.
• At 6 weeks through eighteen months, patients responded "yes" at a
significantly higher rate in the total disc replacement group than in the
arthrodesis group (p < 0.0384).
• At 24 months, the percentage of patients who responded "yes" was
78.2% (111 of 142) in the total disc replacement group compared with
62.1% (thirty-six of fifty-eight) in the arthrodesis group (p = 0.0546).
47. Visual Analog Scores for Satisfaction
Time Point
Total Disc Replacement
Arthrodesis
P Value†
6 weeks
78.93 ± 21.80
72.44 ± 25.03 0.0731
3 months
78.17 ± 23.46
70.87 ± 25.39 0.0056
6 months
77.67 ± 23.02
67.81 ± 24.87 0.0015
12 months
76.53 ± 26.45
67.76 ± 31.01 0.0244
18 months
75.40 ± 28.06
65.49 ± 30.76 0.0375
24 months
77.70 ± 27.95
68.89 ± 30.50 0.0126
*The values are given as the mean and the standard deviation.
†The Wilcoxon rank-sum test was used to compare the total disc replacement and
arthrodesis groups.
48. Narcotic Use
• Preoperatively, 69.1% (114) of 165 patients in the total disc replacement
group and 63.9% (forty-six) of seventy-two patients in the arthrodesis
group reported using narcotics.
• At twenty-four months, there was a significant decrease, favoring the total
disc replacement group, in terms of the percentage of patients using
narcotics (p = 0.0020).
49. Line graph showing the percentage of patients using narcotics for each
surgical treatment over time. (TDR = Total Disc Replacement)
50. Work and Recreation Status
•
Preoperatively, there was no significant difference between the total disc
replacement group (79.4%; 131 of 165) and the arthrodesis group (83.3%;
sixty of seventy-two) in terms of the employment rate (p = 0.5928). Similarly,
at twenty-four months, there was no significant difference between the total
disc replacement group (80.4%; 115 of 143) and the arthrodesis group (86.0%;
forty-nine of fifty-seven) in terms of the employment rate (p = 0.4193).
•
Preoperatively, there was no significant difference between the total disc
replacement group (36.4%; sixty of 165) and the arthrodesis group (43.7%;
thirty-one of seventy-one) in terms of the percentage of patients participating
in recreational activities (p = 0.3099). The percentage of patients participating
in recreational activities had increased in both groups at twenty-four months,
with no significant difference between the total disc replacement group
(84.6%; 121 of 143) and the arthrodesis group (79.7%; forty-seven of fiftynine) (p = 0.4121).
51. Complications
• Major surgery-related complications included one dural tear in the total
disc replacement group (0.6%; 1/165) and 3 dural tears in the arthrodesis
group (4.2%; 3/72).
• Blood loss of >1500 mL occurred in 2/165 (1.2%) of patients in the TDR
group and 2/72(2.8%) of patients in the arthrodesis group.
• One of the two patients in the total disc replacement group sustained an
iliac artery tear
• One patient in the total disc replacement group and the 2 patients in the
arthrodesis group had excessive Oozing from the decompression,
decorticated bone, and graft sites.
• Postoperatively DVT was reported in 2/165 (1.2%) .of patients in the TDR
group and 2/72 (2.8%) of in the arthrodesis group
52. RESULTS
• At twenty-four months, 58.8% (87/ 148 )patients in the TDR group were
classified as a statistical success, compared with 47.8% (32/67)patients in
the arthrodesis group; non-inferiority was demonstrated.
• The mean Oswestry Disability Index in both groups significantly improved
from baseline (p < 0.0001); the mean percentage improvement for the
total disc replacement group was significantly better than that for the
arthrodesis group (p = 0.0282).
• An established clinical criterion for success, a =15-point improvement in
the Oswestry Disability Index from baseline, occurred in 73.2% (109/149 )
patients in the total disc replacement group and 59.7% (37/62)patients in
the arthrodesis group.
53. RESULTS
• The SF-36 physical component scores were significantly better for the total
disc replacement group as compared with the arthrodesis group (p =
0.0141 at twenty-four months).
• VAS scores for satisfaction significantly favored total disc replacement
from 3 to 24 months. At twenty-four months, 78.2% (111/142) patients in
the total disc replacement group and 62.1% (36/58) patients in the
arthrodesis group responded "yes" when asked if they would have the
same surgery again.
• Lumbar spine range of motion on radiographs averaged 7.8° at the
superior disc and 6.2° at the inferior disc in patients with total disc
replacement. Auerbach JD et al 2007, 2009.
• Reduction in narcotics usage significantly favored the total disc
replacement group at twenty-four months after surgery (p = 0.0020).
54. CONCLUSION
• Despite the relatively short duration of follow-up and design limitations,
the present study suggests that two-level lumbar disc arthroplasty is an
alternative to and offers clinical advantages in terms of pain relief and
functional recovery in comparison with arthrodesis.
• Longer-term follow-up is needed to determine the risks for implant wear
and/or degenerative segment changes.
55. SB Charité III
(Metal – poly - metal)
• SB Charite III
• Pro Disc L
• Maverick
(Metal on Metal)
• Flexicore
• Mobidisc
57. Ideal properties of an Implant
• Biocompatible (endure in vivo for up to 40 yrs)
• Biomechanical properties should allow for a nearnormal range of movement and function.
• The design should facilitate safe implantation,
preferably through a modest incision
• The implant must not preclude modern imaging
techniques for periodic monitoring and regard must
be given to the possible need for revision or salvage
procedures.
Total lumbar disc replacement, H. M. Mayer, MD, PhD, Orthopaedic Surgeon,
Neurosurgeon, Associate Professor, 2005, JBJS
58. HOME CARRYING MESSAGE
• Total Disc Replacement proves to an ideal choice of surgical
procedure for the treatment of DDD.
• The promise of Disc tissue regeneration via Gene therapy ,
Tissue engineering is on the horizon.