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    The ICJR Top 50: Numbers 10 to 1

    Today, we conclude our countdown of the most-accessed content of all time on ICJR.net with number 10 through number 1.

    Number 10
    ANTIBIOTICS FOR PERIOPERATIVE PROPHYLAXIS IN TOTAL JOINT ARTHROPLASTY
    Authors: Andrew M. Pepper, MD; Lewis Moss, MD; and Jonathan M. Vigdorchik, MD
    Originally published July 17, 2018

    Prevention of surgical site infection (SSI) – specifically, prevention of periprosthetic joint infection (PJI) – has been a topic of intense interest in the medical and surgical community for the last 2 decades. The reasons for this are numerous, but the most intense focus is on preventing the devastating medical, surgical, and economic consequences of PJI, which is generally regarded as a “preventable” complication in patients undergoing elective total joint arthroplasty.

    The purpose of this article is to discuss:

    • The history of current standards for perioperative antibiotic therapy for prevention of SSI
    • The recent recommendations from the Centers for Disease Control and Prevention (CDC)
    • The available literature on the timing and selection of antibiotics
    • The common issue of prophylactic antibiotics for arthroplasty patients undergoing other invasive medical procedures

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    Number 9
    CMS IS REMOVING THA FROM THE INPATIENT-ONLY LIST
    Originally published November 21, 2019

    The Centers for Medicare and Medicaid Services (CMS) has published its final rule on the Medicare Hospital Outpatient Prospective Payment System (CMS-1717-FC) and the Ambulatory Surgical Center Payment System for calendar year 2020, and as orthopaedic surgeons have been expecting, total hip arthroplasty was removed from the Inpatient-Only List.

    In addition, total knee arthroplasty has been added to the Ambulatory Surgery Center Covered Procedures List.

    The comment period for this final rule ends on Monday, December 2, and the rule is scheduled to take effect on January 1, 2020.

    CMS says that the changes in the rule, “build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System.”

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    Number 8
    WEIGHT-BEARING FOLLOWING ORIF OF UNSTABLE ANKLE FRACTURES
    Authors: Nicole Stevens, MD, and Philipp Leucht, MD
    Originally published August 6, 2016

    Ankle fractures are  common orthopaedic injuries and account for approximately 13% of all fractures. Current dogma dictates postoperative immobilization and non-weight-bearing for 6 weeks. This has been shown to lead to joint stiffness, muscle atrophy, and inconvenience for the patient.

    The goal of the study by Dehghan et al was to compare 2 postoperative rehabilitation protocols for unstable ankle fractures treated with open reduction and internal fixation:

    • The current standard of 6 weeks non-weight-bearing in a cast
    • Weight-bearing as tolerated and formal ankle range of motion therapy starting at 2 weeks

    The primary outcome in this study was time to return to work, and secondary outcomes included ankle range of motion, functional and health outcome scores and complication rates.

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    Number 7
    MANAGING ROTATOR CUFF TEARS IN YOUNG PATIENTS
    Authors: Filippo Familiari, MD, Alan Gonzalez-Zapata, MD, and Edward G McFarland, MD
    Originally published on August 11, 2014

    Muscles and tendons of the rotator cuff, like those elsewhere, show changes in morphology, histology, biomechanics, and integrity as the individual ages. Common wisdom suggests that “normal tendons do not tear.” This observation is supported by the fact that tendinosis usually does not make tendons susceptible to tearing until the fourth decade of life. The incidence of tears of the Achilles tendon, patellar tendon, long head of the biceps, and rotator cuff increases linearly with age, a relationship that is particularly applicable to rotator cuff abnormality.

    The increasing incidence of rotator cuff syndrome (abnormalities ranging from painful tendinosis to full-thickness tears of the tendons) is supported by epidemiologic, cadaveric, imaging, and surgical studies. Rotator cuff tears occur more commonly in middle-aged and older patients than in young patients; studies have shown that less than 1% of rotator cuff tears occur in patients less than 20 years old.

    In patients age 30 years or younger, rotator cuff tendons are generally healthy, robust, and unless subjected to repetitive overhead activities, less likely to be the source of symptoms. The number of recorded cases in adolescents is limited.

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    Number 6
    DISTAL TIBIA NON-UNION AFTER SEEMINGLY SUCCESSFUL FRACTURE REDUCTION
    Author: Brandon J. Yuan, MD
    Originally published September 24, 2018

    A 48-year-old male patient with a history of nicotine dependence (less than 1 pack per week) presents with a closed extra-articular distal tibia and fibula fracture that occurred in a twisting injury on a wet surface, falling from standing height. No CT scan was obtained, and the patient was taken to the operating room for surgical fixation of this injury.

    Many high-energy distal tibia fractures that require open exposures through the zone of injury warrant consideration for temporary external fixation to restore stability, length, and alignment. This will allow time for the soft tissue swelling associated with the initial trauma to resolve prior to imparting additional surgical trauma to the limb.

    However, the history and radiographs of this injury imply a relatively low-energy mechanism, and the soft tissue envelope may be acceptable for immediate definitive surgical management. In addition, use of a medullary device may be appropriate for this extra-articular injury, allowing for minimal additional soft tissue trauma to the distal leg.

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    Number 5
    GRAFT CHOICES IN ACL RECONSTRUCTION
    Authors: Alberto Castelli, MD; Simone Perelli, MD; Enrico Ferranti, MD; Eugenio Jannelli, MD; Giacomo Zanon, MD; and Francesco Benazzo, MD
    Originally published January 29, 2018

    Anterior cruciate ligament (ACL) tears are common orthopaedic injuries affecting mostly young and active patients, with nearly 200,000 ACL reconstructions annually in the US. ACL injuries occur across all age groups, but their prevalence is higher in adolescent athletes and active adults as a consequence of the increasing intensity of sports training. ACL insufficiency results in joint instability and altered gait kinematics, and it can lead to chronic pain and degenerative changes in the knee.

    Arthroscopic reconstruction is the standard approach to treating ACL tears, but the optimum graft choice remains controversial. Surgeons in the US most often use bone-patellar tendon-bone (BPTB) and 4-strand hamstring tendon autografts. A study of surgeons in Italy showed a preference for hamstring autografts.

    Some authors have suggested that BPTB autograft is the best graft choice due to its faster integration and greater proportion of patients returning to pre-injury activity levels. However, others prefer hamstring autograft due to reduced donor site morbidity, anterior knee pain, and lower extensor strength deficit.

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    Number 4
    10 TIPS AND TRICKS FOR ORIF OF PROXIMAL HUMERUS FRACTURES
    Authors: Joseph J. King, MD; Corey A. Jones, BS; and Thomas W. Wright, MD
    Originally published July 20, 2016

    1. Ensure appropriate operating room setup

    When performing open reduction internal fixation (ORIF) of a proximal humerus fracture, we prefer to place the patient in the lazy beach chair position, with the head of the table elevated to around 30°. Raising the head of the table any higher would make it more difficult to obtain a Grashey view x-ray.

    The thorax should be situated as close to the edge of the table as possible to allow free access to and mobilization of the shoulder. The patient’s head should be at the top edge of the table to allow for an easier axillary lateral x-ray. The head should be secured to the table with tape to prevent it from falling off the table with shoulder manipulation.

    The fluoroscopy machine should come in from the top of the table after the table has turned 90° so the contralateral side is next to anesthesia.

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    Number 3
    LATISSIMUS DORSI AND TERES MAJOR TEAR IN A THROWING ATHLETE
    Authors: Brandon J. Erickson, MD, and Anthony A. Romeo, MD
    Originally published October 10, 2018

    Injuries to the latissimus dorsi (LD) and teres major (TM) are uncommon problems affecting athletes, specifically those who participate in overhead sports such as baseball. Unfortunately, because these injuries are uncommon, they are often difficult to diagnose and, therefore, are commonly missed, leading to problems with these athletes returning to sport. Treatment for these injuries varies and can involve rest and rehabilitation or surgical repair.

    The LD takes its origin from the lower ribs, iliac crest, and spinous processes of the lower 6 thoracic vertebrae. As it heads towards its insertion on the floor of the intertubercular groove of the humerus, it externally rotates 90° to allow the muscle to work more efficiently. The TM originates on the dorsal surface of the inferior angle of the scapula and inserts on the medial lip of the intertubercular of the humerus. The TM is deep and cranial to the LD. Cadaveric studies have found the LD and TM tendons often coalesce before insertion; occasionally the TM will insert onto the LD.

    The LD and TM are strong internal rotators of the humerus and are most active during the late cocking and acceleration phases of the pitching cycle; they also have a small amount of activation during the deceleration phase. The LD and TM are important structures in the kinetic chain of pitching, whereby the force generated from the lower extremity and trunk is transferred to the humerus and upper extremity. These muscles play a role in protecting the shoulder from excess shear and manufacturing pitch speed.

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    Number 2
    THE DISAPPEARING STEM: THE CHANGING HUMERAL SIDE OF SHOULDER ARTHROPLASTY
    Authors: Jed Maslow, MD; John Paul Wanner, MD; Howard Routman, DO; and Ian Byram, MD
    Originally published February 21, 2019

    Total shoulder arthroplasty (TSA), like hip and knee arthroplasty, has undergone a major transformation in technique and technology over the last century, driven by a demand for increasing efficiency and improved outcomes. The rate of TSA is increasing by 6% to 13% per year, translating to 5 times as many surgeries performed in 2010 than in 2000. As the popularity of the procedure continues to increase, so does the cost, rising at least $900 per procedure per year.

    Although external factors such as price and policy may have some influence, advances in implants and surgical technique allow surgeons to focus on restoring anatomy, minimizing soft tissue disruption, and planning for possible revision surgery.

    The origin of TSA dates back to Themistocles Gluck, a German surgeon who developed ivory endoprostheses in the 1880s, and Jules-Emile Péan, a French surgeon credited with the first successful shoulder arthroplasty in 1893.

    The operation did not begin to gain popularity until 1955 when Charles Neer published a case series on 12 patients who had undergone shoulder arthroplasty to treat proximal humerus fractures. The initial implant design he used was a monoblock stemmed prosthesis without glenoid resurfacing.

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    Number 1
    MPFL RECONSTRUCTION IN A YOUNG ATHLETE
    Authors: Neel A. Gupta, MD; Nimit Patel, MD; and Shyam Brahmabhatt, MD
    Originally published April 19, 2018

    Recurrent patellar instability continues to be a challenging problem for orthopaedic surgeons, with incidence increasing each year. The rate of patellar dislocation is highest in the 10- to 17-year-old age group, with reported rates of 29% to 43%. In addition, females have a 33% increased prevalence of acute patellar dislocation compared with males.

    Disruption of the medial patellofemoral ligament (MPFL) is thought to be the essential lesion resulting in recurrent patellar dislocation. According to several anatomic and biomechanical studies, the MPFL is the most important restraint to lateral patellar displacement from 0° to 30° of knee flexion. The MPFL is compromised in the vast majority of acute dislocations, and its capacity to heal is limited.

    There is some debate regarding the management of a first-time patellar dislocation. In a randomized controlled trial, Palmu et al and Hennrikus and Pylawka reported no significant difference in long-term subjective or functional results between operative and non-operative treatment of first-time traumatic patellar dislocations. As a result, non-operative treatment continues to be the standard of care for first-time traumatic patellar dislocation, except in cases involving osteochondral fractures, vastus medialis avulsions, large osteochondral fragments, or concomitant intra-articular abnormalities such as meniscal tears.

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