James M. Rizkalla M.D.

Rizkalla, J. M., B. P. Gladnick, A. A. Bhimani, D. S. Wood, K. J. Kitziger and P. C. Peters, Jr. (2020). “Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.” Curr Rev Musculoskelet Med May 22;1-9. [Epub ahead of print].

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PURPOSE OF REVIEW: The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic. RECENT FINDINGS: SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting “elective” surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely “elective” procedure, versus an “urgent” procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into “elective” versus “urgent” categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one’s peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

Bhimani, A. A., J. M. Rizkalla, K. J. Kitziger, P. C. Peters, Jr., R. D. Schubert and B. P. Gladnick (2020). “Surgical automation reduces operating time while maintaining accuracy for direct anterior total hip arthroplasty.” J Orthop 22: 68-72.

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Objective: Investigate the efficiency/accuracy of surgical automation versus manual component implantation in DA THA. Methods: Retrospective review of 111 hips: 51 hips via automation and 60 hips via manual technique for DA THA. Results: OR time averaged 8 min faster in the Automated group, compared to Manual group (p = 0.0009). Average femoral size was one size larger in the Automated group compared to Manual group (p = 0.007). No clinically significant differences were found between Manual and Automated groups for cup position or limb-length discrepancy. One calcar fracture occurred in the Automated group. Conclusion: Surgical automation is efficient and accurate for DA THA.

Rizkalla, J. M., T. Lines and S. Nimmons (2019). “Classifications in Brief: The Denis Classification of Sacral Fractures.” Clin Orthop Relat Res 477(9): 2178-2181.

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In their original description, Denis et al. described three zones of injury: Zone I: injuries located lateral to the neuroforamina; Zone II: injuries that involve the neuroforamina, but not the spinal canal; and Zone III: injuries that extend into the spinal canal, with primary or associated fracture lines. The study found that neurologic injuries occurred in 5.9% of fractures lateral to the sacral foramina (Zone 1). In transforaminal fractures (Zone 2), 28.4% of patients had a neurologic deficit. Meanwhile, central fractures (Zone 3) had the highest likelihood of neurologic injury (56.7%) [6] (Fig. 1). Furthermore, Zone III fractures are often divided into four different types, including: (1) flexion fracture with anterior angulation, (2) flexion fracture with anterior angulation and posterior displacement, (3) extension fractures with anterior displacement, and (4) comminuted fracture of the upper segment of the sacrum without displaced alignment of sacrum. (Excerpt from text, p. 2179; no abstract available.)