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Mark W Pagnano

Publications and source records attributed to Mark W Pagnano.

At least 19 recordsLinked to original sources
PubMed2006

Rotating platform knees: an emerging clinical standard: in opposition.

As surgeons, we share the common goals of making total knee arthroplasty as reliable, as reproducible, and as durable as we can. For that reason, we are almost compelled to investigate the rotating platform knee because of the contentions that it might improve patellar tracking, decrease lateral release rates, improve flexion, or perhaps give better wear characteristics over the long term. But when we take a step back and carefully examine the scientific data from 20 years of clinical experience with the rotating platform knee, the data speak for itself. To date, there are no demonstrated clinical advantages in regard to wear, survivorship, kinematics, range of motion, or patellar function. The rotating platform design then is really just another knee design, clinically indistinguishable from many well-functioning, fixed-bearing total knee designs.

Arthroplasty, Replacement, Knee↗
PubMed2006

Minimally invasive total knee arthroplasty with an optimized subvastus approach.

The minimally invasive surgery subvastus approach provides very good exposure through a small incision, preserves all 4 attachments of the quadriceps to the patella, does not require patella eversion, minimizes disruption in the suprapatellar pouch, and allows rapid and reliable closure of the knee. The patella and entire distal portion of the extensor mechanism can be retracted into the lateral gutter of the knee where they remain out of the way and allow direct visualization of both femoral condyles. When coupled with instruments designed specifically for small incision surgery, the modified subvastus approach is reliable, reproducible, and safe. Using a simple set of retractors the surgeon can perform the surgery without making any blind cuts or freehand cuts and that enhances surgical accuracy and patient safety.

Arthroplasty, Replacement, Knee↗
PubMed2006

Assuring a painless total hip arthroplasty: a multimodal approach emphasizing peripheral nerve blocks.

A highly effective comprehensive multimodal pain protocol has evolved at our institution for both primary and revision hip and knee arthroplasty. At the center of this protocol are peripheral nerve blocks to deliver postoperative pain relief. Total hip arthroplasty patients receive a lumbar plexus block with an indwelling catheter. Total knee arthroplasty patients receive a femoral nerve block with an indwelling catheter and also get a single-shot sciatic nerve block. Before surgery, patients are given a long-acting oral narcotic medication and a nonsteroidal anti-inflammatory. After surgery, oral medications are given on a set schedule and include acetaminophen, a nonsteroidal anti-inflammatory, and a long-acting oral narcotic. Outstanding pain control is achieved without parenteral narcotics and allows early physical therapy, early return to self-care, and improved patient satisfaction.

Analgesics↗
PubMed2006

Anatomy of the extensor mechanism in reference to quadriceps-sparing TKA.

The introduction of minimally invasive surgical techniques in total joint arthroplasty has ushered in a range of new terminology that often is unclear. One such term is quadriceps-sparing total knee arthroplasty (TKA). We examined 100 knees intraoperatively in 100 patients at the time of TKA, dissected 45 entire cadaveric leg specimens, and did high-resolution 3-Tesla magnetic resonance imaging scans on five normal knees to specifically determine: (1) the distal most insertion point of the vastus medialis obliquus; (2) the angle of insertion of the vastus medialis obliquus; and (3) the length of the vastus medialis obliquus tendon. The medial anatomy of the extensor mechanism was consistent. The inferior edge of the VMO inserted at or near the midpole of the patella in each case. The tendon inserted at 50 degrees (range, 46 degrees - 52 degrees). One hundred of the 150 patients (66%) had a tendon that measured 1.2 +/- 0.1 cm, whereas 50 of 150 patients (33%) had a substantially longer tendon (2.2 +/- 0.2 cm). Any medial arthrotomy that extends more proximal than the midpole of the patella detaches a portion of the quadriceps tendon. The term "quadriceps sparing" should not be applied to any surgical approach with a capsular incision that extends more proximal than the midpole of the patella.

Adult↗
PubMed2006

Patients preferred a mini-posterior THA to a contralateral two-incision THA.

The two-incision total hip arthroplasty (THA) technique has been touted as offering substantially faster recovery than other methods of THA, but direct comparison studies in similar groups of patients have not been done. We sought to determine if there was a difference in the early functional outcome after a two-incision THA compared to a mini-posterior THA as measured by the time to reach defined milestones of daily activity. We also evaluated which procedure the patients preferred. Twenty-six patients underwent staged bilateral total hip arthroplasties with a two-incision minimally invasive THA on one hip and a mini-posterior THA on the contralateral hip. The same comprehensive anesthesia and rapid rehabilitation protocol was used after each operation. Patients were reviewed retrospectively a minimum of 6 months after the second total hip arthroplasty. There were no differences in the time to discontinue ambulatory aids, return to driving, climb stairs, return to work, or walk 1/2 mile. Sixteen of 26 patients preferred the mini-posterior total hip arthroplasty and two patients had no preference. The added surgical technical difficulty of the two-incision minimally invasive total hip arthroplasty was not rewarded with an earlier return to functional activities and more patients preferred their mini-posterior total hip arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMed2006

Muscle damage during MIS total hip arthroplasty: Smith-Petersen versus posterior approach.

Decreased muscle damage is a reported benefit of minimally invasive surgical (MIS) approaches in total hip arthroplasty (THA). We compared the extent and location of muscle damage during THA using the MIS anterior Smith-Petersen and MIS posterior surgical approaches. THA was performed in six human cadavers (12 hips). One hip was assigned to the Smith-Petersen approach and the contralateral hip to the posterior approach. Muscle damage was graded with a technique of visual inspection to calculate a proportion of surface area damage. Less damage occurred in the gluteus minimus muscles and minimus tendon with the Smith-Petersen approach. A mean of 8% of the minimus muscle was damaged via the Smith-Petersen approach, compared to 18% via the posterior approach. The tensor fascia latae muscle was damaged (mean of 31%), as well as direct head of the rectus femoris (mean 12%) during the Smith-Petersen approach. The piriformis or conjoined tendon was transected in 50% of the anterior approaches to mobilize the femur. The posterior approach involved intentional detachment of the piriformis and conjoined tendon and measurable damage to the abductor muscles and gluteus minimus tendon in each specimen. Clinical outcome studies and gait analysis are necessary to ascertain the functional implications of these findings.

Aged↗
PubMed2006

Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block.

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede physical therapy and rehabilitative efforts and delay hospital dismissal. Traditionally, postoperative analgesia after total joint replacement was provided by either intravenous patient-controlled analgesia or epidural analgesia. Each, however, had disadvantages as well as advantages. Peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. In several studies, unilateral peripheral block provided a quality of analgesia and functional outcomes similar to those of continuous epidural analgesia and superior to those of systemic analgesia, but with fewer side effects because of their opioid-sparing properties. Peripheral nerve block techniques may be the optimal analgesic method following total joint arthroplasty.

Acetaminophen↗
PubMed2005

Functional results after revision of well-fixed components for stiffness after primary total knee arthroplasty.

Between 1990 and 2001, 16 well-fixed, aseptic, primary total knee arthroplasties were revised in 15 patients for a diagnosis of stiffness. Patients were followed for a mean of 42 months (range, 2-6 years). Of 15 patients, 10 (66%) were satisfied with the results of the procedure. The mean Knee Society pain score improved from 28 to 65 points, and the mean functional score improved from 45 to 58 points. The mean arc of motion improved from 40 degrees preoperatively to 73 degrees postoperatively. Recurrent stiffness required additional intervention in 4 knees (3 patients, 25%). The results of revision of a well-fixed, stiff, primary total knee arthroplasty were mixed in our hands and provided only modest improvements in pain, function, and arc of motion. Key words: knee, arthroplasty, stiffness, revision, arthrofibrosis.

Aged↗
PubMed2005

Flexion instability without dislocation after posterior stabilized total knees.

UNLABELLED: Flexion instability after cruciate-retaining total knee arthroplasty has been well documented. We identified an analogous patient group with symptomatic flexion instability without dislocation after primary posterior stabilized total knee arthroplasty. We sought to determine the typical symptoms and exam findings that lead to the diagnosis, to assess the reliability of revision total knee arthroplasty as a treatment, and to assess the technical difficulties encountered during revision total knee arthroplasty. Between 1995 and 2001, 10 patients had revision of a well-fixed posterior stabilized total knee arthroplasty for isolated symptomatic flexion instability. The typical constellation of symptoms and physical findings included a sense of instability without giving way, recurrent knee effusions, multiple areas of soft tissue tenderness about the knee, and substantial anterior tibial translation at 90 degrees of flexion. The revision operation focused on balancing the flexion and extension gaps while taking care to fill the enlarged flexion gap. Revision total knee arthroplasty was reliable in alleviating pain (mean Knee Society Pain scores improved from 68 points preoperatively to 89 points postoperatively), improving stability (nine of 10 patients had < 5 mm anterior tibial translation postoperatively) and improving patient satisfaction (nine of 10 patients were satisfied). We had no particular technical difficulties with the revision total knee arthroplasty procedures and had reliably achieved well-balanced flexion and extension gaps. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗
PubMed2005

Prevention of wound contamination using DuraPrep solution plus Ioban 2 drapes.

The use of the preoperative skin preparation DuraPrep is thought to enhance the adhesion qualities of an incise drape. If there is less drape lift it was hypothesized that there may be a reduction in wound contamination. We did a single-center, randomized trial to determine if a preoperative skin preparation containing DuraPrep solution plus Ioban 2 drapes reduced wound contamination in total joint replacement surgery compared with a povidone iodine scrub and paint plus Ioban 2 drapes. Secondary research questions focused on comparisons of differences in drape lift and cost between the two groups. Of the 176 evaluable patients, the proportion of patients with a contaminated wound was similar in the two groups (DuraPrep 28.0% versus povidone iodine 36.4%). The mean drape lift in the DuraPrep group was less than the povidone iodine group (1.5 cm versus 9.9 cm respectively). The mean cost of prepping was lower for the DuraPrep group compared with the povidone iodine group (dollars 93.36 and dollars 248.91, respectively). A preoperative skin preparation regimen containing DuraPrep solution plus Ioban 2 drapes is equivalent to a povidone iodine scrub and paint and Ioban 2 for the prevention of wound contamination during total joint replacement surgery. Improved drape lift and cost may influence the choice between the two methods.

Adult↗
PubMed2005

The Knee Society system of standardized abbreviations for surgery of the arthritic knee.

A new standardized system of abbreviations has been adopted by the Knee Society to bring clarity and brevity to scientific reports involving the arthritic knee. This system works by using a set of core abbreviations that are modified with prefixes, suffixes, and superscript notations to indicate succinctly the surgical approach, the procedure used, and the type of prosthesis implanted.

Abbreviations as Topic↗
PubMed2005

Revision total knees done for extensor problems frequently require reoperation.

UNLABELLED: We retrospectively reviewed 361 patients who had a revision total knee arthroplasty done for an extensor mechanism problem to assess the prevalence, etiology, and risk factors for subsequent reoperation. The prevalence of reoperation was 23% because 84 patients were reoperated on one or more times. The average time to the first reoperation was 2.4 years. The total number of reoperations was 127 with 58 patients reoperated on once, 15 reoperated on twice, and 11 reoperated on three or more times. The cumulative risk of a reoperation for any reason after index revision was 7% at 1 year, 19.6% at 5 years, and 35.9% at 10 years. The most common reason for reoperation was a new or recurrent patellofemoral problem, which accounted for 33% of the first reoperations. The risk of reoperation was substantially lower for patients that had femoral or tibial component malrotation corrected at the time of revision TKA. The risk of reoperation after revision TKA for an extensor mechanism complication increased in patients operated on in the 1990s compared with patients operated on in the 1970s and 1980s. LEVEL OF EVIDENCE: Therapeutic study, Level-IV-1 (case series). See the Guidelines for authors for a complete description of levels of evidence.

Arthroplasty, Replacement, Knee↗
PubMed2005

Two-incision THA had modest outcomes and some substantial complications.

UNLABELLED: Proponents of two-incision total hip arthroplasty suggest the technique is minimally invasive and promotes rapid rehabilitation with a low prevalence of complications. We applied the two-incision total hip arthroplasty technique to a consecutive group of unselected patients with primary degenerative arthritis to determine the technical difficulty of the operation as measured by the operative time compared with a standard posterior approach, the safety of the operation as measured by the prevalence of complications compared with a standard posterior approach, and the early functional outcome measured by the time to return to activities of daily living as compared with a previous study of the two-incision technique in selected younger patients. The 80 patients included 45 women and 35 men with a mean age of 70.5 years. The patients treated with a two-incision method had longer operative times and substantially more complications than did the patients treated with a standard posterior approach. The early functional outcomes in this group of unselected patients were modest when compared with the previous results in selected younger patients. Patient and surgeon enthusiasm for the potential benefits of the two-incision total hip arthroplasty should be tempered by the modest early outcomes and the substantial prevalence of complications found in this group of typical patients having total hip arthroplasty. LEVEL OF EVIDENCE: Prognostic study, Level III (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Adult↗
PubMed2005

The Frank Stinchfield Award: muscle damage after total hip arthroplasty done with the two-incision and mini-posterior techniques.

Some surgeons have suggested that a minimally invasive two-incision approach allows total hip arthroplasty to be done without cutting or damaging any muscle or tendon. To our knowledge that claim has not been supported by any published clinical or basic science data. Our purpose in doing this study was to quantify the extent and location of damage to the abductor and external rotator muscles and tendons after two-incision and mini-posterior total hip arthroplasty. Ten cadavers (20 hips) were studied. In each cadaver one hip randomly was assigned to the two-incision group and the contralateral hip was assigned to the mini-posterior group. After inserting the total hip arthroplasty components the muscle damage was assessed using a technique described previously. Damage to the muscle of the gluteus medius and gluteus minimus was substantially greater with the two-incision technique than with the mini-posterior technique. Every two-incision total hip replacement caused measurable damage to the abductors, the external rotators, or both. Every mini-posterior hip replacement caused the external rotators to detach during the exposure and had additional measurable damage to the abductor muscles and tendon. We do not support the contention that a two-incision total hip arthroplasty is done without cutting muscle or tendon. None of the two-incision hip replacements were done without cutting, reaming, or damaging the gluteus medius or gluteus minimus muscle or external rotators.

Aged↗
PubMed2005

Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes.

BACKGROUND: There is relatively little information about quadriceps tendon tears after total knee arthroplasty. The purpose of this study was to determine the prevalence of this condition and the outcomes of patients who had a tear of the quadriceps tendon after a total knee arthroplasty. METHODS: From a cohort of 23,800 primary total knee arthroplasties, we identified twenty-four patients who had a rupture of the quadriceps tendon postoperatively. Ten additional patients had the total knee arthroplasty done elsewhere and were referred for care after sustaining a tear of the quadriceps tendon. Thus, the study group consisted of thirty-four patients, and all had at least two years of follow-up. Eleven patients had a complete tear, and twenty-three had a partial tear. RESULTS: The prevalence of a quadriceps tendon tear after total knee arthroplasty was 0.1% (twenty-four of 23,800). Seven patients with a partial tear were treated nonoperatively, and all had a satisfactory outcome. One patient with a complete tear was treated nonoperatively and had an unsatisfactory result. Of the ten patients treated operatively after a complete tear, four subsequently had rerupture of the repaired tendon and four had a satisfactory outcome. Of the sixteen patients with a partial tear treated operatively, only one had rerupture and twelve had a satisfactory outcome. Complications occurred in eleven of the twenty-six patients managed operatively. CONCLUSIONS: The prevalence of complications was high, and the outcomes were poor for seven of the eleven patients who had a complete quadriceps tendon tear after total knee arthroplasty. Patients who sustained a partial tear and were treated nonoperatively had no complications and had uniformly good outcomes.

Adult↗
PubMed2005

Surgical treatment of the middle-aged patient with arthritic knees.

Arthritic knee disease is increasingly more common in the active aging population. The pathology seen in this patient group can run a spectrum of localized degenerative change through tricompartmental arthritis. Nonsurgical options to treat early symptoms are well known and often are effective. When nonsurgical management has failed, surgical intervention often is warranted. Arthroscopic debridement is considered in select patients with mechanical symptoms. Osteotomy continues to have a role in the treatment of young, active patients and may be particularly appropriate in combination with articular cartilage procedures. Unicompartmental and total knee arthroplasty are reliable treatments for patients with advanced stages of degenerative arthritis.

Anterior Cruciate Ligament↗
PubMed2004

Total knee arthroplasty for patients 90 years of age and older.

This study was done to review the reliability, durability, and safety of primary and revision total knee arthroplasty for patients 90 years of age and older. Because little data exist about the safety or efficacy of total knee replacement in this elderly population some physicians may be hesitant to recommend elective surgery to patients of this age. Fifty-one total knee replacements were done for 41 patients age 90 to 102 years (mean, 92 years). Forty-four primary total knee replacements and seven revision total knee replacements were done. Each patient was followed up until death or for a minimum of 2 years (mean, 4.0 years). The Knee Society pain scores improved significantly for the primary and revision groups from preoperative mean scores of 30 and 29 points to latest followup scores of 86 and 87 points, respectively. One patient died in the early postoperative period of causes related to the operation. The remaining patients have lived an average of 4.4 +/- 2.2 years after the primary knee arthroplasties and 5.7 +/- 2.8 years after the revision knee arthroplasties. No knees have required revision subsequently. Total knee replacement was reliable, durable, and safe in this group of patients older than 90 years. Primary care physicians and surgeons should be aware that primary and revision total knee replacement can be done safely and effectively for patients 90 years and older and result in years of marked pain relief for those patients.

Age Factors↗