2. Surgeon’s Wish List
Arthroplasty Device Improvements
Matthew J. Dietz, MD
Department of Orthopaedics
Adult Reconstruction
mdietz@hsc.wvu.edu

3. Disclosures
• Scientific Advisory Board
• Synotrac, DEF Technologies,
• Research Committee Member
• AAHKS
• At-Large Member
• WV Orthopaedic Society

4. Surgeon’s Wish List
“I want an official Red Ryder
carbide action, two-hundred shot
range model air rifle!”
“You’ll Shoot Your Eye Out!”
via a Christmas Story

5. Young Doctors and Wish Lists:
No Weekend Calls, No Beepers
Matt Richtel Jan 7, 2004
Controllable Lifestyle
Family
“Shift work”

6. Who we really are…

7. Primary Arthroplasty Revision Arthroplasty
By 2030
THA  174% (500k/yr)
TKA  673% (3.5 M/yr)
By 2030
THA  137%
TKA  601%
2015
Projected Needs
-- Kurtz JBJS 2007

8. What do we want…
Better Toys
1) Efficient Safe
Surgical Care
2) Good Outcomes
3) Limit Complications

9. Baby Boomers
Shorter Hospital Stays
Quicker return to activity
Reduced pain
Safe surgical
experience

10. Baby Boomers
Cost Reduction
Reduce Resources
Hospital Length of Stay
Hospital Cost

11. Efficient Safe Surgical Care
• On-Demand Medicine
• Apps
• Concierge service
• Access
• Tele-medicine
• Same day Surgery

12. Use of Smartphones in Orthopaedics
Clinical
Reference Tools Risk Calculators
--Bozic CORR 2013
Billing
-- Franko CORR 2011

13. Improved Outcomes
• 15-30% TKA are Dissatisfied
• Patient Reported Outcomes
• Value based care
• Efficient Registries
• Electronic Medical Record
-- Bourne CORR 2010
--Jones Rheum Dis Clin N Am
-- Noble CORR 2006
Knee Jerk Reaction to EMR

14. Improved Outcomes
• Ease of Data Collection
• Data Entry
• Data Analysis
28% patient care vs
43% Data Entry
-- Am J. Emer Med.

15. Improved Outcomes
• Better Implants
• Osseointegration
• Patient Specific
• Wary of the “Better Mousetrap”

16. Intraoperative Navigation
-- Scuderi Orthop Clin N. America 2014
Better Implants …. in Better Position

17. Robotics
Better Implants …. in Better Position

18. Robotics
Better Implants …. in Better Position
Limitations
Cost
Cumbersome
Time

19. Additive Manufacturing

20. Additive Manufacturing
• Patient Specific Implant
• Address Needs
• Easily Implantable
• Adaptable

21. Prosthetic Joint Infection is Deadly
0
10
20
30
40
50
60
70
80
90
100
5 Year Survival
Choi et al. JOA 2013
Zmistowski JBJS 2013

22. Prosthetic Joint Infection is Deadly
Choi et al. JOA 2013
Zmistowski JBJS 2013
0
10
20
30
40
50
60
70
80
90
100
5 Year Survival
33% Mortality

23. Infection Burden
-- Kurtz JOA 2012
$1.62 Billion
in
2020

24. Limited Option for PJI

25. “Gold Standard”
Removal of all prosthetic material including cement
Gold Standard

26. Gold Standard
Cement Spacer

27. Gold Standard
Cement Spacer

28. Gold Standard
Interval period of IV Antibiotics
(Typically 6 weeks)

29. Gold Standard Two Stage Exchange
• Greater morbidity and mortality
-- Berend K. CORR 2012

30. Debridement
What is infected?
What is not?

31. Debridement
Contraction
Consistency
Color
Circulation
-- --Bowyer JAAOS 2006
4 C’s

32. We can do better…

33. Diagnosis of Infection
• Problem
• No Gold Standard
-- Bedair CORR 2011
White Blood Cell Cut-off from Joint Aspiration

34. Diagnosis of Infection

35. MSIS Definition of PJI
Major Criteria
-Two positive periprosthetic cultures with phenotypically identical
organisms
-A sinus tract communicating with the joint
Minor Criteria (3 of the following)
- Elevated CRP and ESR
-Elevated synovial fluid white blood cell count or ++ change on leukocyte
esterase strip
-Elevate synovial Polymorphonuclear neutrophil percentage (PMN%)
-Positive histological analysis of periprosthetic tissue
-A Single Positive Culture
-- Zmitstowski. JOA 2014

36. α - Defensin
--Deirmengian CORR 2014

37. • Limitations
• Requires fluid aspiration
• Variability depending on clinic situation
• Send out test
α - Defensin
--Deirmengian CORR 2014

38. Diagnosis
• Less/Non-invasive
• Accurate
• Rapid Point of Care Test

39. What I want What we Get

40. Summary
• Prevent Burnout
• Improve Outcomes
• Additive Manufacturing Useful
• Improved Debridement Strategies
• Advance Infection Detection

41. Thank You