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OR Notes

Take a front row seat to complex and innovative surgeries and procedures
Date: Mar 2016

Marking site for surgical incision for revision hip replacement

For a transcript of the April 26 virtual grand rounds by Orthopaedics Chair Dr. Vincent Pellegrini on hip revision  on the free case-sharing app Figure 1, search @MUSChealth or #muscrounds on the Figure 1 app (iOS and Android) or at figure1.com.

To view (graphic) surgical photographs of the surgery, click here for a pdf of the Progressnotes article on revision hip replacement.

 

Of the approximately 350,000 hip replacements performed each year in the U.S., about 10% will eventually require revision surgery—typically, 15-20 years after the original surgery—due to infection, wear, instability, or component loosening.

Because revision hip replacements are more challenging and typically performed in an older population, they are best done at high-volume centers with robust critical care and advanced anesthesia services. At such centers, revision hip replacements are now commonly performed in patients older than 80 years of age, enhancing their mobility and enabling them to preserve an active lifestyle.

Vincent D. Pellegrini, M.D., Chair of the Department of Orthopaedics at MUSC Health, and the other surgeons on the joint replacement team—Harry A. Demos, M.D., Jacob M. Drew, M.D., and Richard J. Friedman, M.D.—perform more than 650 hip and knee replacements annually, more than a quarter of which are revisions. In 2014, the program was awarded Joint Commission specialty certification for total hip, knee, and shoulder joint replacement.

Report of a Case
An 80-year-old man, who had undergone primary cemented hip replacement 16 years previously, presented with “start-up” thigh pain. Each time he stood or initiated gait, he experienced thigh pain for the first few steps that resolved in a dozen steps. Radiographs revealed that the cement had loosened from the femur, resulting in the cycle of pain that repeated every time the patient stood up and the femoral stem sank to a stable position in the bone. The cement loosened due to bone loss, resulting from a foreign body reaction to microscopic particles that were generated as the plastic liner of the replacement wore.

Revision hip replacement was advised and involved removal of the femoral component, the associated cement, and the plastic liner, with implantation of a new plastic liner and a cementless femoral component. Bone from which cement has been extracted tends to be smooth and does not provide reliable fixation for new cement; for this reason, cementless femoral stems, which have a roughened surface texture to which bone can attach, are preferred for hip revision surgery.

Often in hip revision surgery, the greater trochanter and the attached muscles must be cut to allow access to the femoral canal for cement removal. In this case, an anterolateral approach provided good femoral access without the need for trochanteric osteotomy and the patient was able to begin exercise immediately after surgery. He will use a walker or cane for only three to four weeks, much less than would have been required after trochanteric osteotomy.

A pathologist was on hand to analyze tissue samples for infection. Had infection been detected, all components would have been removed, the patient would have received several weeks of intravenous antibiotics, and a second surgery would have been scheduled to implant the new components.

Want to learn more about this case and see more than a dozen surgical photographs? Ask Dr. Pellegrini questions in real time during his virtual grand rounds (a live event) on April 26 at 8:00 pm on the free Figure 1 app (iOS and Android).

Follow more surgical cases on the MUSC Health profile (@MUSChealth) on the free Figure 1 app (iOS and Android).

To consult with an MUSC Health joint replacement surgeon or to refer a patient, contact nurse navigator Kathleen Case at casek@musc.edu.

kidney donor with Give Life tattoed on knuckles

Search #muscrounds on the free case-sharing app Figure 1 (http://figure1.com) to view the annotated photographs and associated comments from the MUSC Health virtual grand rounds on kidney transplant.

Kristy Hokett (pictured at left) has the words “Give Life” tattooed on her knuckles. She was moved to get the tattoo when she saw the good that came from her aunt’s decision to donate her organs upon her death. A few years later, when her father tried to donate a kidney to his former colleague Thomas House, but was not a good candidate, Kristy offered to step in. In the past, all of these acts of generosity would have come to nothing when it was determined that Kristy was not a good match for Thomas. Today, with the availability of the kidney chain program, Kristy was able to give her kidney to another well-matched recipient, ensuring Thomas in turn received the kidney he needed. 

Three MUSC Health transplant surgeons (see photo below) were involved in this series of transplants—Satish N. Nadig, M.D., Ph.D.Charles F. Bratton, M.D.; and Prabhakar Baliga, M.D., Chair of the Department of Surgery at MUSC Health. Using surgical photos from this series of transplants, Nadig led a virtual grand rounds on the free case-sharing app Figure 1 (Android and iOS) on January 27, 2016. To view the annotated photographs and comments from the virtual grand rounds, search #muscrounds on Figure 1 (http://figure1.com). To see all posts of surgical photographs from MUSC Health, search @MUSChealth.

The Need for Living Donation

There are currently more than 100,000 people waiting for life-saving kidney transplants in the United States. Four out of five patients in need of a kidney go without one, many of whom must in the meantime rely on dialysis. Extended times on dialysis are associated with worse outcomes after transplant and place a huge economic burden on the health care system.

Living donors are crucial to reducing these statistics. An organ from a living donor lasts twice as long and provides the highest quality at the lowest cost. Living donor organs both reduce wait times and begin to function faster after transplant.

The MUSC Health Kidney Transplant Program, which began in 1968, numbers among the nation’s leading academic transplantation programs. MUSC Health is also South Carolina’s only Living Donor Transplant Center, kidney transplant surgerywhere more than 800 organs have been donated by living donors. 

Kidney chains remove the constraint of compatibility from living donation, expanding the pool of patients who can benefit. In effect, they unleash the power of generosity inherent in the decision to donate.

MUSC Health initiated its first kidney chain in 2013 (read story here) and participated in the longest chain the NKR has ever done—35 transplants—in 2015. The January 2016 chain involving kidney donor Kristy Hokett was MUSC Health’s twelfth, and the seventh that it originated. Hokett’s surgery was featured on the Figure 1 app to help build awareness among physicians and medical students about the importance of this revolutionary approach to kidney transplant.

How the Chain Works

Using a sophisticated algorithm, the National Kidney Registry (NKR) helps identify donors and recipients who would likely be good matches, though they may live in distant parts of the United States. More than 70 institutions, including MUSC, participate in the registry.  

The chain of kidney transplants is set off with an altruistic donation. A good Samaritan donor offers up a kidney without designating a recipient. The incompatible donor of the first recipient in turn “pays it forward” by donating his or her kidney to a recipient that is a good match for that kidney (View Figure), and the process continues on until a kidney comes back to the institution where the good Samaritan donation occurred or is given to a patient enrolled in the Children and High Panel-Reactive Antibody (PRA) Program (CHIP).

Paying It Forward

Good Samaritan donor Candace Potter initiated the January 2016 chain involving Kristy Hokett. She was a match for Thomas, enabling Kristy to donate her kidney to a well-matched recipient in the Charleston area.

“Your donor can give to the NKR list and it expands your options,” says Sara Parker, R.N., MUSC’s NKR coordinator. “A patient with a living donor is not bound to that one donor—that donor is a ticket into an exchange where there is greater genetic diversity and a greater chance of a good match.” In short, having a living donor, albeit an incompatible one, gains one right of entry into the NKR, where the right kidney might await.

By helping solve the problem of incompatibility, the kidney chain makes more living donations possible. For the donor, the kidney chain offers an opportunity to magnify the impact of their good deed. Instead of helping one, the donor is instrumental in helping many.

 For more information on the availability of kidney chains at MUSC, contact Sarah Parker, R.N., NKR coordinator, at burbages@musc.edu

For more information on innovation at MUSC Health, see Progressnotes, MUSC's medical magazine (MUSChealth.org/pn).

The Living Donor Institute

The MUSC Living Donor Institute is striving to create a nationally recognized program to serve as a leading resource for transplant patients and live donors through the pursuit of innovation. Its goals are to improve living donation education and access, improve transplant quality, and support research into high-tech alternatives to transplant.