Fred D Cushner

Albert Einstein College of Medicine, New York City, New York, United States

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Publications (47)100.33 Total impact

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    ABSTRACT: Perioperative pain control after total knee arthroplasty may be insufficient, resulting in insomnia, antalgic ambulation, and difficulty with rehabilitation. Current strategies, including the use of femoral nerve catheters, may control pain but have been associated with falls, motor blockade, and quadriceps inhibition. Periarticular infiltration using the appropriate technique and knowledge of intraarticular knee anatomy may increase pain control and maximize rehabilitation. Copyright © 2015 Elsevier Inc. All rights reserved.
    Orthopedic Clinics of North America 11/2014; · 1.70 Impact Factor
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    ABSTRACT: While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been previously demonstrated with arthroscopy. The purpose of this study was to examine the clinical value and cost-effectiveness of routine histological examination of knee arthroscopy specimens.METHODS: Retrospective chart analysis of 3797 consecutive knee arthroscopies by two surgeons from 2004 to 2013 at three affiliated hospitals within one health-care system was undertaken. Pathology reports regarding tissue removed during partial meniscectomies and anterior cruciate ligament reconstructions were reviewed to determine if the results altered patient care. The total costs of histological examination were estimated in 2012-adjusted U.S. dollars. The cost per health effect was determined by calculating the cost per discrepant and discordant diagnosis.RESULTS: The prevalence of concordant diagnoses was 99.3% (3769 of 3797), the prevalence of discrepant diagnoses was 0.7% (twenty-seven of 3797), and the prevalence of discordant diagnoses was 0.026% (one of 3797). The total cost of histological examinations was estimated to be $371,810. The total cost of the pathology cost per discrepant diagnosis was $13,771, and the cost per discordant diagnosis was $371,810.CONCLUSIONS: Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management. Histological examination of surgical specimens from arthroscopic knee surgery did not alter patient care and increased costs. We suggest that gross and histological examination of tissue removed during knee arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.
    The Journal of bone and joint surgery. American volume. 06/2014; 96(11):917-921.
  • Joseph W Greene, Ajit J Deshmukh, Fred D Cushner
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    ABSTRACT: Venous thromboembolism (VTE) is a relatively rare complication of arthroscopic surgery but has the potential to cause significant morbidity and even mortality. VTE has been reported after shoulder and knee arthroscopy prompting controversial guidelines to be proposed. More limited studies are available regarding hip and ankle arthroscopy and 1 case of deep venous thrombosis in the contralateral leg status after hip arthroscopy exists. No reports have been published regarding VTE after elbow or wrist arthroscopy to these authors' knowledge. In this article, a systematic review of the literature was conducted to analyze the incidence, treatment, and prevention of thromboembolic complications in arthroscopy.
    Sports medicine and arthroscopy review 06/2013; 21(2):69-74. · 1.16 Impact Factor
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    ABSTRACT: BACKGROUND: The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research (®), the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system. QUESTIONS/PURPOSES: The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications. METHODS: A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events. RESULTS: The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society. CONCLUSIONS: Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.
    Clinical Orthopaedics and Related Research 04/2013; · 2.79 Impact Factor
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    ABSTRACT: Patellofemoral arthroplasty (PFA) is a viable treatment option of the patient with isolated patellofemoral arthritis. Some of the purported advantages of PFA compared with total knee arthroplasty (TKA) include less invasive approach, less bone resection and tissue destruction, decreased operative time, shorter rehabilitation, better knee kinematics, and decreased blood loss. This study compared the blood loss associated with PFA with that of a cohort of patients with TKA. A proposed benefit of partial knee arthroplasty is less blood loss. Patellofemoral replacement seems not to have this benefit and blood loss prevention initiatives similar to those of TKA should be maintained.
    Orthopedic Clinics of North America 11/2012; 43(5):e44-7. · 1.70 Impact Factor
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    ABSTRACT: BACKGROUND: Despite the importance of complications in evaluating patient outcomes after TKA, definitions of TKA complications are not standardized. Different investigators report different complications with different definitions when reporting outcomes of TKA. QUESTIONS/PURPOSES: We developed a standardized list and definitions of complications and adverse events associated with TKA. METHODS: In 2009, The Knee Society appointed a TKA Complications Workgroup that surveyed the orthopaedic literature and proposed a list of TKA complications and adverse events with definitions. An expert opinion survey of members of The Knee Society was used to test the applicability and reasonableness of the proposed TKA complications. For each complication, members of The Knee Society were asked "Do you agree with the inclusion of this complication as among the minimum necessary for reporting outcomes of knee arthroplasty?" and "Do you agree with this definition?" RESULTS: One hundred two clinical members (100%) of The Knee Society responded to the survey. All proposed complications and definitions were endorsed by the members, and 678 suggestions were incorporated into the final work product. The 22 TKA complications and adverse events include bleeding, wound complication, thromboembolic disease, neural deficit, vascular injury, medial collateral ligament injury, instability, malalignment, stiffness, deep joint infection, fracture, extensor mechanism disruption, patellofemoral dislocation, tibiofemoral dislocation, bearing surface wear, osteolysis, implant loosening, implant fracture/tibial insert dissociation, reoperation, revision, readmission, and death. CONCLUSIONS: We identified 22 complications and adverse events that we believe are important for reporting outcomes of TKA. Acceptance and utilization of these standardized TKA complications may improve evaluation and reporting of TKA outcomes.
    Clinical Orthopaedics and Related Research 07/2012; · 2.79 Impact Factor
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    ABSTRACT: Modern techniques have been successful over the past several years in reducing the amount of transfusions that occur after total joint arthroplasty. Although improvements have been made, transfusion rates after unilateral replacements still range from 4% to 46% and 31% to 72% in bilateral cases. Owing to the high incidence of transfusion rates, there are concerns with regard to acute postoperative anemia and wound complications for the knee arthroplasty patient. In addition, we have entered an era of minimally invasive surgery with rapid recovery and it is felt that limiting the blood loss into the joint can improve patient’s immediate results; if not, the long-term results that occur after a joint arthroplasty procedure. Traditionally, allogeneic transfusions have been used to treat the anemia associated with surgery. Aside from the risks associated with allogeneic transfusions, which include disease transmission, allergic reactions, fluid overload, and transfusion reactions, there is a sense of failure when a patient has to be transfused after a joint replacement procedure. This study will focus on a multimodal blood avoidance protocol and will be divided into 3 sections. The first is the preoperative section in which the patient is evaluated and prepared for the planned total knee arthroplasty procedure. The second section describes intraoperative techniques that help limit blood loss. The third section entails a postoperative rehabilitation protocol that maximizes the patient’s recovery while minimizing blood loss after the procedure. This study will cover current blood conservation techniques and our own blood management protocol.
    Techniques in Knee Surgery 11/2011; 10(4):188–197.
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    ABSTRACT: Preoperative identification of a knee at risk for wound healing after total knee arthroplasty (TKA) allows the surgeon to apply a soft tissue expansion technique to expand the available tissue for closure and healing after TKA. A consecutive series of 64 soft tissue expansions were performed for 59 cases of conflicting incisions and 5 cases of severe angular deformity, with a mean of 3.5 previous surgeries. An average 2.1 expanders were used for a total volume of 359 mL. Expansion took a mean of 70 days during which 14 minor and 7 major complications occurred. There were 8 post-TKA complications, 5 of which required a return to the operating room. Soft tissue expansion is a safe, prophylactic technique that provides adequate coverage in this complex subset of patients.
    The Journal of arthroplasty 08/2011; 27(3):362-7. · 2.37 Impact Factor
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    ABSTRACT: Standard medial parapatellar arthrotomies of 10 cadaveric knees were closed with either conventional interrupted absorbable sutures (control group, mean of 19.4 sutures) or a single running knotless bidirectional barbed absorbable suture (experimental group). Water-tightness of the arthrotomy closure was compared by simulating a tense hemarthrosis and measuring arthrotomy leakage over 3 minutes. Mean total leakage was 356 mL and 89 mL in the control and experimental groups, respectively (p = 0.027). Using 8 of the 10 knees (4 closed with control sutures, 4 closed with an experimental suture), a tense hemarthrosis was again created, and iatrogenic suture rupture was performed: a proximal suture was cut at 1 minute; a distal suture was cut at 2 minutes. The impact of suture rupture was compared by measuring total arthrotomy leakage over 3 minutes. Mean total leakage was 601 mL and 174 mL in the control and experimental groups, respectively (p = 0.3). In summary, using a cadaveric model, arthrotomies closed with a single bidirectional barbed running suture were statistically significantly more water-tight than those closed using a standard interrupted technique. The sample size was insufficient to determine whether the two closure techniques differed in leakage volume after suture rupture.
    The journal of knee surgery 03/2011; 24(1):55-9.
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    American journal of orthopedics (Belle Mead, N.J.) 09/2010; 39(9 Suppl):29-31.
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    ABSTRACT: The Global Orthopaedic Registry (GLORY) offers insights into multinational practice patterns of venous thromboembolism (VTE) prophylaxis in orthopedic surgery, based on data from 15,020 patients undergoing primary total knee arthroplasty or primary total hip arthroplasty from 2001 to 2004. Registry data show that the first choice for in-hospital VTE prophylaxis was low-molecular-weight heparin. Multimodal prophylaxis was common. Warfarin was more widely used in the USA than elsewhere in the world. GLORY data suggest that real-world practice often fails to meet the standards for prophylaxis recommended in the American College of Chest Physicians evidence-based guidelines, particularly in the USA. However, many US orthopedic surgeons may follow other practice guidelines, causing an underestimation of prophylaxis us in this study. Warfarin in the USA often failed to achieve recommended target International Normalized Ratio (INR) values. This paper reviews the GLORY practice findings in light of the contemporary literature on best practices for VTE prophylaxis in orthopedic patients.
    American journal of orthopedics (Belle Mead, N.J.) 09/2010; 39(9 Suppl):14-21.
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    ABSTRACT: The Global Orthopaedic Registry (GLORY) has been designed to monitor a broad range of complications and outcomes that occur following total hip arthroplasty (THA) and total knee arthroplasty (TKA). GLORY provides global 'real-world' data, in contrast to the data generated by the controlled conditions of clinical trials. The results to date show an overall incidence of both in-hospital and post-discharge complications of approximately 7% in THA patients and 8% in TKA patients. The most common in-hospital complications in THA patients are fractures (0.6%) and deep-vein thrombosis (DVT) (0.6%), whereas in TKA patients DVT (1.4%) and cardiac events (0.8%) are most common. The most common post-discharge complications in both THA and TKA patients are reoperation due to bleeding, wound necrosis, wound infection, or other causes; and DVT. Bleeding complications were less common than other adverse events in both groups (in-hospital rates of 0.48% and 0.83%, respectively). Functional outcomes improved after surgery in both groups, as expected. Younger patients and patients who had been discharged directly to their homes seemed to have the greatest improvement in functional outcome after surgery.
    American journal of orthopedics (Belle Mead, N.J.) 09/2010; 39(9 Suppl):22-8.
  • Fred D Cushner, Michael P Nett
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    ABSTRACT: Although significant progress has been made over the past 25 years in preventing thromboembolic disease in patients undergoing total hip and total knee arthroplasty, important questions remain unanswered. Few would debate the need to seek a balance between maximal antithrombotic efficacy and minimal bleeding in choosing a thromboprophylactic strategy, but there is less agreement as to how efficacy should be defined, and whether efficacy and safety (however each is defined) are intrinsic to the thromboprophylactic agent chosen or depend as well on exogenous factors, ranging from the timing of drug administration to surgical technique. Differences between recent guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) illustrate these unanswered questions. The AAOS guidelines focus solely on preventing symptomatic pulmonary embolism and ignores the importance of other acute and chronic manifestations of venous thromboembolic disease. The ACCP, on the other hand, does consider these other manifestations of venous thromboembolic disease, and thus reaches very different conclusions about what constitutes effective thromboprophylaxis. Despite these questions and uncertainties, there are fundamental truths: (1) venous thromboembolism (VTE) is a known and serious complication of total joint arthroplasty, and (2) evidence-based thromboprophylaxis works. Gaps between guideline-recommended and actual orthopedic practice must be reduced.
    Orthopedics 12/2009; 32(12 Suppl):62-6. · 1.05 Impact Factor
  • Fred D. Cushner, Michael P. Nett
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    ABSTRACT: For the last 30 years, surgeons have balanced the need for deep-venous thrombosis (DVT) prophylaxis with the need to avoid complications following total joint arthroplasty. Debate continues regarding prophylaxis against venous thromboembolism (VTE). Despite established guidelines and continued research, no consensus exist as to what agent affords the best balance between reducing DVT rates and minimizing the incidence of bleeding and wound complications. New oral anticoagulants offer the ease of oral administration and excellent efficacy, but remain unavailable in the United States and may lead to increased bleeding. New portable pneumatic compression devices look promising. They allow outpatient use and may improve compliance, but their exact role in the future of DVT prophylaxis remains undetermined.
    Seminars in Arthroplasty 12/2009; 20(4):251-254.
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    ABSTRACT: Anterior cruciate ligaments (ACLs) and posterior cruciate ligaments (PCLs) from 45 osteoarthritic knees were histologically examined to evaluate the frequency and grade the severity of degenerative changes, which were correlated with radiologic grade of arthritis and severity of deformity at the knee. Immunohistochemical staining was used to identify neurofilaments in 10 knees. A histologic score was generated for both cruciates based on changes found on light microscopy. The ACL was severely degenerated, absent, or disrupted in knees with radiologic arthritis higher than grade 3 and varus deformity exceeding 15°. The PCL was moderately degenerated in most knees irrespective of the grade of arthritis and severity of deformity. Neurofilaments were present in all 10 PCLs and absent in 4 ACLs.
    The Journal of arthroplasty 07/2009; 24(4):657; author reply 657. · 2.37 Impact Factor
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    ABSTRACT: Prophylaxis for venous thromboembolism is recommended for at least 10 days after total knee arthroplasty; oral regimens could enable shorter hospital stays. We aimed to test the efficacy and safety of oral rivaroxaban for the prevention of venous thromboembolism after total knee arthroplasty. In a randomised, double-blind, phase III study, 3148 patients undergoing knee arthroplasty received either oral rivaroxaban 10 mg once daily, beginning 6-8 h after surgery, or subcutaneous enoxaparin 30 mg every 12 h, starting 12-24 h after surgery. Patients had mandatory bilateral venography between days 11 and 15. The primary efficacy outcome was the composite of any deep-vein thrombosis, non-fatal pulmonary embolism, or death from any cause up to day 17 after surgery. Efficacy was assessed as non-inferiority of rivaroxaban compared with enoxaparin in the per-protocol population (absolute non-inferiority limit -4%); if non-inferiority was shown, we assessed whether rivaroxaban had superior efficacy in the modified intention-to-treat population. The primary safety outcome was major bleeding. This trial is registered with, number NCT00362232. The primary efficacy outcome occurred in 67 (6.9%) of 965 patients given rivaroxaban and in 97 (10.1%) of 959 given enoxaparin (absolute risk reduction 3.19%, 95% CI 0.71-5.67; p=0.0118). Ten (0.7%) of 1526 patients given rivaroxaban and four (0.3%) of 1508 given enoxaparin had major bleeding (p=0.1096). Oral rivaroxaban 10 mg once daily for 10-14 days was significantly superior to subcutaneous enoxaparin 30 mg given every 12 h for the prevention of venous thromboembolism after total knee arthroplasty. Bayer Schering Pharma AG, Johnson & Johnson Pharmaceutical Research & Development.
    The Lancet 06/2009; 373(9676):1673-80. · 39.21 Impact Factor
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    ABSTRACT: Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 09/2008; 466(8):2009-11; author reply 2012-4. · 2.79 Impact Factor
  • Henry D. Clarke, Fred D. Cushner
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    ABSTRACT: Backside wear in conventional modular metal-backed tibial components in total knee arthroplasty has been a concern for over a decade. Numerous strategies exist to reduce motion and, therefore, wear at this interface. These include redesigning the locking mechanisms and optimizing the surface finish of modular components using a mobile-bearing tibial component designed to encourage desirable motion and returning to monoblock all-polyethylene and metal-backed tibial components. New designs of monoblock components that may be used with and without cement are available. The most important element of the surgical technique when using these devices is to optimize the exposure of the tibial plateau, including the posterolateral corner, to ensure that correct tibial component rotation is obtained.
    Techniques in Knee Surgery 05/2008; 7(2):115-125.
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    ABSTRACT: Despite evidence-based guidelines for venous thromboembolism (VTE) prevention after total hip or knee arthroplasty (THA/TKA), many patients may not receive effective prophylaxis. Our objective was to analyze data from the multinational Global Orthopaedic Registry (GLORY) to evaluate the compliance of surgeons with the American College of Chest Physicians (ACCP) guidelines for VTE prevention. Data from 8160 patients who had undergone a primary, unilateral, elective THA (n = 3950) or TKA (n = 4210), and had at least 3 months of follow-up were analyzed. Almost all patients received a form of recommended prophylaxis. Compliance with guidelines in terms of type, duration, start time, and dose was achieved for 47% of THA and 61% of TKA patients in the USA, and 62% of THA and 69% of TKA patients outside the USA. Warfarin use, mostly in the USA, was fully compliant in 33% of THA and 48% of TKA patients. Low-molecular-weight heparin use was fully compliant in 63% of THA and 72% of TKA patients in the USA, and 67% of THA and 73% of TKA patients outside the USA. Although almost all THA and TKA patients both inside and outside the USA received prophylaxis, a large proportion did not receive treatment in accordance with the ACCP guidelines. Our study may have overestimated the use of recommended prophylaxis as some participating investigators may have had a specific interest in VTE prophylaxis. Furthermore, although analyses were restricted to approximately three-quarters of patients who had outpatient follow-up data, their characteristics were similar to those in the entire population.
    Current Medical Research and Opinion 02/2008; 24(1):87-97. · 2.37 Impact Factor
  • Gwo-Chin Lee, Fred D Cushner
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    ABSTRACT: The purpose of this study was to evaluate the blood levels of patients preparing for total knee arthroplasty (TKA) who were enrolled in a preoperative autologous donation program. The charts and hospital records of 70 consecutive patients who underwent primary unilateral TKA between 2000 and 2002 were retrospectively reviewed. Study participants were instructed to donate one unit of blood approximately 4 weeks prior to surgery. Predonation and preoperative hemoglobin levels were assessed throughout the study and transfusion requirements were recorded. Transfusions were administered only when warranted by clinical symptoms. The mean initial (predonation) hemoglobin concentration was 14.1 g/dL. The mean number of days donations were made prior to surgery was 13 +/- 3.3 days. Prior to surgery, the average hemoglobin concentration dropped to 12.8 g/dL. Fifty (71%) patients had a hemoglobin value > 13.0 g/dL prior to their autologous donation, but only 30 (43%) patients had blood levels > or = 13.0 g/dL following blood donation. Postoperatively, the mean hemoglobin concentration in the recovery room was 11.6 g/dL and dropped to a nadir of 10.8 g/dL on postoperative day 3. Overall, 91% of patients required autologous blood transfusion following TKA but no patients required allogeneic blood transfusions. Preoperative autologous donation was associated with a decrease in preoperative hemoglobin levels and with a high rate of autologous transfusion based on clinical symptoms of postoperative anemia.
    The journal of knee surgery 07/2007; 20(3):205-9.

Publication Stats

703 Citations
100.33 Total Impact Points


  • 2005–2011
    • Albert Einstein College of Medicine
      • Orthopaedic Surgery
      New York City, New York, United States
  • 2009
    • Southside Hospital
      Bay Shore, New York, United States
  • 2008–2009
    • Center for Sports Medicine and Orthopaedics
      Chattanooga, Tennessee, United States
  • 2007
    • Drexel University College of Medicine
      Philadelphia, Pennsylvania, United States
  • 2000–2005
    • Beth Israel Medical Center
      • Department of Orthopedic Surgery
      New York City, New York, United States
  • 1999
    • Mayo Foundation for Medical Education and Research
      Rochester, Michigan, United States
    • St. Charles Hospital
      Port Jefferson, New York, United States
  • 1988
    • Medical University of South Carolina
      • Department of Orthopaedic Surgery
      Charleston, SC, United States