Search

BackgroundGenicular nerve radiofrequency ablation (GNRFA), including conventional, cooled, and pulsed techniques, has been used in the management of symptomatic knee osteoarthritis (OA). This new and innovative treatment option has the capacity to decrease pain and improve function and quality of life in certain patients. GNRFA is reserved for patients with symptomatic knee OA who have had failure of conservative treatment and have had failure of or are poor candidates for surgery. GNRFA has been shown to consistently provide short-term (3 to 6-month), and sometimes longer, pain relief in patients. GNRFA has been demonstrated to be safe to administer repeatedly in patients who respond well to this minimally invasive procedure.DescriptionGNRFA is a 2-step procedure. First, patients are given a diagnostic block under fluoroscopy or ultrasound guidance. Specifically, 1 mL of lidocaine is injected using a 20-gauge, 3.5-in (8.9-cm) spinal needle around the superior lateral, superior medial, and inferior medial genicular nerve branches. The diagnostic block is extra-articular. If the patient reports a ≥50% reduction in baseline pain for a minimum of 24 hours following the injection, then the patient is a candidate for genicular ablation. The osseous landmarks for the diagnostic block are exactly the same as for the ablation procedure. Both procedures are well tolerated in the office setting under local skin anesthesia or can be done in the operating room under conscious sedation using a low-dose sedative such as midazolam for anxious patients. General anesthesia is not required for GNRFA. This procedure is most commonly performed by interventional pain specialists but may also be performed by any physician with appropriate training. In some jurisdictions, physician assistants and nurse practitioners may perform this procedure subject to their supervision requirements.AlternativesConservative treatment for symptomatic knee OA includes weight loss management, physical and aquatic therapy, bracing, lateral wedge insoles, transcutaneous nerve stimulation, nonsteroidal anti-inflammatory drugs in combination with a proton pump inhibitor, autologous blood-based therapies, and cortisone and hyaluronic acid injections1,2. Surgical treatment for symptomatic knee OA includes knee arthroscopy, high tibial osteotomy, total knee replacement, and unicompartmental knee replacement in patients without lateral compartment disease2. It should be noted that there is some evidence suggesting that steroid injection, viscosupplements, and arthroscopy are not effective for the management of knee OA.RationaleThermal GNRFA differs from all other treatment alternatives because this procedure causes denaturing of the 3 sensory nerves primarily responsible for transmitting knee pain from an arthritic joint to the central nervous system. In this procedure, heating occurs from an intense alternating electrical field at the tip of the cannula, which produces sufficient heat to denature the proteins in the target tissue. The accepted heating parameters for this procedure are 70° to 80°C for 60 or 90 seconds. A commonly raised question is whether this procedure precipitates a Charcot-type joint. The Charcot joint involves much more than reduced innervation; it occurs in the context of chronically compromised vascularity and altered soft-tissue characteristics as well as peripheral neuropathy. Moreover, a Charcot-type joint does not develop because the deafferentation of the weight-bearing joint is partial3. To our knowledge, no Charcot-type joints have been reported after this procedure. Conversely, data from an animal study have shown that selective joint denervation may lead to the progression of knee OA4. The ablation procedure is done outside the knee joint, unlike alternatives such as intra-articular therapies and surgery. The effectiveness of nonsurgical knee OA interventions in alleviating pain and improving joint function is generally inadequate1. However, GNRFA appears to be an emerging alternative for patients who have had failure of conservative and surgical treatments. It is not uncommon in our clinical practice for patients to achieve adequate pain control following ablation for up to 1 year. GNRFA provides temporary relief from symptomatic knee OA because it does not eliminate the potential for peripheral nerve regrowth and regeneration, and thus pain, to return.

Management of Enlarging tracheoesophageal fistula (TEF) with Voice Prosthesis in Laryngectomized Head and Neck Cancer Patients. Objectives: An enlarging TEF following voice prosthesis placement impacts patient quality of life, risks airway compromise, and can lead to aspiration pneumonia. Pharyngoesophageal strictures have previously been reported to be associated with TEF enlargement and leakage. We describe a series of patients with enlarging TEFs after Tracheoesophageal puncture (TEP) for voice prosthesis who required pharyngoesophageal reconstruction. Methods: Retrospective case series of laryngectomized H&N cancer patients with primary or secondary TEP who underwent surgical management for enlarging TEF site between 6/2016–11/2022. Results: Eight patients were included. The mean age was 62.8 years old. Seven patients had a history of hypothyroidism. Of seven with prior H&N radiation history, two had both historical and adjuvant radiation. Two of the eight TEPs were placed secondarily. Mean time from TEP to enlarging TEF diagnosis was 891.3 days. Radial forearm‐free flaps were used in five patients. Six had stenosis proximal to the TEF whereas one had distal stenosis and one had no evidence of stenosis. Mean length of stay was 12.3 days. Mean follow‐up was 400.4 days. Two required a second free flap for persistent fistula. Conclusion: Surgical reconstruction of enlarging TEFs due to TEP/VP placement is effective in combination with addressing underlying pharyngeal/esophageal stenosis contributing to TEF enlargement and leakage. Radial forearm‐free flaps have the additional benefit of a long vascular pedicle to access more distant and less‐irradiated recipient vessels. Many fistulae are resolved after the first flap reconstruction, but some may require subsequent reconstruction in case of failure. Level of Evidence: 4 Laryngoscope, 134:198–206, 2024 [ABSTRACT FROM AUTHOR]

Though the role of chronic kidney disease (CKD) has been studied previously in primary arthroplasty procedures of the hips and knees, there is a paucity of literature analyzing CKD's impact on surgical outcomes in revision total knee arthroplasty (rTKA) patients. As the number of patients with CKD requiring revision surgery increases, more vigilant pre-operative and post-operative measures can be taken to ensure successful outcomes. This retrospective study sought to 1) determine differences in demographics and preoperative comorbidities of patients with normal or mild CKD and those with moderate/severe CKD and 2) establish moderate/severe CKD as an independent risk factor for complications in the 30-day postoperative period in patients undergoing rTKA. The ACS-NSQIP database was queried for patients who had undergone rTKA from 2005 to 2016. Patient were assigned to one of five CKD severity classes after eGFR calculation and were further stratified into two cohorts: stages 1/2 vs. stages 3/4/5. After propensity matching to generate a matched normal/mild CKD cohort of rTKA patients, univariate and multivariate analyses were used to assess differences and the impact of severe CKD on the risk for complications. There were significant differences in several demographic features, comorbidities, and complications between the two cohorts upon univariate analyses. Upon multivariate analyses, CKD of moderate/severe/failure status was found to be a significant independent risk factor for acute renal failure (OR 18.097, 95% CI 4.970–65.902, p < 0.001), blood transfusions (OR 1.697, 95% CI 1.500–1.919, p < 0.001), return to the operating room (OR 1.257, 95% CI 1.009–1.566, p = 0.041), extended length of stay (OR 1.707, 95% CI 1.292–2.255, p < 0.001), and mortality (OR 2.165, 95% CI 1.116–4.200, p = 0.022) in the 30-day postoperative period. This current study found moderate/severe CKD to be an independent risk factor for several complications and should guide healthcare professionals for better patient-optimization. Orthopaedic surgeons should factor in CKD severity in the management of patients undergoing rTKA to effectively mitigate the effects of adverse events. [ABSTRACT FROM AUTHOR]

Byline: William E. Spangler, David P. Strum, Luis G. Vargas and Jerrold H. May In the face of increasing demands for services and tighter constraints on resources, medical centres are searching for ways to improve efficiencies and reduce costs. This paper describes the design and development of a system, called Resource Coordination for Surgical Services (RCSS), that is intended to help managers improve overall utilisation of surgical suites.

Byline: William E. Spangler, David P. Strum, Luis G. Vargas, Jerrold H. May This chapter explores cost reduction and capacity planning in surgical services. Classical operating suite (OR) utilisation is defined as the ratio of total OR time used to total OR time budgeted, but that definition of utilisation allows scheduling inefficiencies and costs to go undetected. Instead, a more accurate description of the overall use of resources can be achieved by dividing classical utilisation into under-utilisation and over-utilisation, and incorporating those measures within a minimal cost analysis model. The model, which was developed from a study of surgical case records collected over six years, indicates that the potential cost savings are significant.

A new study investigates how the lognormal distribution, proposed for modeling surgical data, can be fitted to surgical procedure times.

This research describes a constraint-based heuristic model of capacity segmentation for outpatient facilities used to estimate the effect of segmentation constraints on stakeholders. Growth of free-standing ambulatory surgery centres has been dramatic in recent years with institutions being urged by governments and insurers to segment inpatients (IP) and outpatients (OP) to reduce costs and improve services. Critics of segmentation argue it is a false economy to separate inpatients and outpatients since pooling of patients in large IP facilities offers economies of scale and opportunities for parallel processing, not to mention elimination of infrastructure. We implemented a constraint-based heuristic model of capacity segmentation for OP facilities and used it to estimate the effect of segmentation on stakeholders. [ABSTRACT FROM AUTHOR]

The plans for Resource Coordination for Surgical Services system (RCSS) incorporate a distributed objectbase with a coordinating server. User-centered information screens are customized for each geographic location in surgical services. User interfaces are designed to mimic paper lists and worksheets used by health care providers. Patient-specific and site-specific data will be entered and maintained by providers at each geographic location, but also rebroadcast and displayed for all providers. Although RCSS is primarily a communications system, it will also support review of surgical utilization and operative scheduling. [ABSTRACT FROM PUBLISHER]