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    The ICJR Top 50: Numbers 20 to 11

    Continuing our countdown of the most-accessed content on ICJR.net with number 20 through number 11.

    Number 20
    SEVERE CORROSION OF A MODULAR DUAL MOBILITY ACETABULAR COMPONENT
    Authors: Erik Zachwieja, MD, and Peter F. Sharkey, MD
    Originally published January 29, 2020

    The use of modular dual mobility (MDM) components during primary and revision total hip arthroplasty (THA) has grown substantially over the past 5 years, increasing from 6.7% of primary THAs in 2012 to 12% in 2018 and from 19.5% of revision THAs in 2012 to 30.6% in 2018 in the US alone.

    Increased utilization is likely driven by the enhanced articulation stability provided by dual mobility implants and the increased head sizes they allow. Large femoral head size coupled with motion at 2 articulating surfaces increases the hip’s range of motion prior to impingement, resulting in a low incidence of dislocation.

    Furthermore, the advent of modularity has facilitated the ease of implantation. The original dual mobility construct utilized a monoblock cobalt-chromium acetabular component that did not allow for supplemental screw fixation or attachment of an insertion handle, causing difficulties with implant insertion. Contemporary dual mobility designs consist of a standard titanium acetabular component and a modular cobalt-chromium articular insert.

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    Number 19
    REVISION ACL RECONSTRUCTION: CURRENT CONCEPTS
    Authors: Abigail Campbell, MD, MSc; Michael Zacchilli, MD; and Michael Alaia, MD
    Originally published May 22, 2018

    Primary reconstruction of the anterior cruciate ligament (ACL) is performed more than 100,000 times per year in the US. Reported failure rates for ACL reconstruction (ACLR) are between 3% and 7%. Causes of failure include:

    • Infection
    • Hardware complication
    • Motion loss
    • Recurrent instability

    Recurrent instability can present with either a torn or intact graft and can be classified as early failure (less than 6 months after surgery) or late failure (more than 6 months after surgery). Patients can also have subjective laxity without measured laxity due to pain, stiffness, or poor muscular control. Daniel et al demonstrated that a side-to-side difference greater than 3 mm in anteroposterior (AP) laxity with the knee at 30° is correlated with structural failure of the ACL graft.

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    Number 18
    EVALUATING AND MANAGING FLEXION INSTABILITY AFTER TKA
    Originally published October 8, 2018

    In 1993, Arlen D. Hanssen, MD, and David G. Lewallen, MD, noticed a phenomenon among total knee arthroplasty (TKA) patients who were being referred to them with “weird infections”: The patients didn’t have infections, they had flexion instability.

    Dr. Hanssen believes flexion instability is the number 1 cause of the so-called “unhappy knee.” But 25 years after he and Dr. Lewallen first identified flexion instability, and 20 years since they and their colleagues from Mayo Clinic first wrote about it, he is amazed by how many surgeons either don’t understand flexion instability, deny that it’s a clinical issue, or don’t know how to evaluate and treat patients who clearly have symptoms of this pathology.

    Speaking at ICJR’s 7th Annual Revision Hip & Knee Course, Dr. Hanssen reviewed the presenting symptoms, physical examination, and stepwise surgical plan for correcting flexion instability.

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    Number 17
    ORIF WITH INTRAMEDULLARY NAIL FOR A PROXIMAL HUMERUS FRACTURE
    Authors: Justin Wong, MD, and Luke S. Austin, MD
    Originally published November 11, 2015

    A 66-year-old female presented to the emergency department with significant left shoulder pain and swelling following a slip and fall on the ice. She was unable to move the shoulder due to the pain.

    History and Physical Examination

    • No significant past medical or surgical history
    • Height 5 feet, 5 inches; weight 150 pounds
    • Swelling of the left shoulder, tender to palpation
    • Lateral arm sensation normal; positive deltoid activation
    • No tenderness or pain at elbow/forearm
    • Intact sensation in median/radial/ulnar nn
    • Intact but limited elbow flexion/extension
    • Intact wrist/finger extension and flexion

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    Number 16
    EXPLORING A NEW ALIGNMENT PARADIGM IN TOTAL KNEE ARTHROPLASTY
    Originally published January 17, 2019

    Durability of the implanted prosthesis has been the goal of total knee arthroplasty (TKA) since the earliest days of the procedure.

    And, it’s been achieved: At the recent ICJR East ISK Hip & Knee Course, Mark W. Pagnano, MD, from Mayo Clinic in Rochester, Minnesota, reported that combined registry data show about a 1.25% risk of TKA revision per year – which means the vast majority of TKA patients will have a knee that will last them 10 to 30 years.

    Orthopaedic surgeons are now turning their attention to improving function of the knee, hoping to close the “satisfaction gap” between total hip and total knee patients. Some surgeons are looking at solving alignment issues with computer navigation and/or robotics, other are considering whether advanced sensor-tensor devices can help with ligament balancing, and still others are investigating new implants to preserve the anterior cruciate ligament.

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    Number 15
    COVID-19: POSTPONING ELECTIVE SURGICAL PROCEDURES
    Originally published March 18, 2020

    Across the US – and around the world – elective surgical procedures like joint replacement are being deferred in favor of prioritizing healthcare resources for the management of patients with coronavirus disease (COVID-19).

    The Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the American College of Surgeons (ACS) have separately issued recommendations that impact elective procedures in outpatient and inpatient facilities in the US.

    • The CDC recommends that surgeons reschedule elective surgeries as necessary and shift elective urgent inpatient diagnostic and surgical procedures to outpatient settings, when feasible. Non-urgent outpatient visits should be rescheduled as necessary.
    • The CMS recommends that non-essential surgeries and procedures be delayed during the outbreak of novel coronovirus to preserve personal protective equipment (PPE), beds, and ventilators for use with patients with COVID-19.
    • The ACS recommends that hospitals, health systems, and surgeons enact plans to minimize, postpone, or cancel elective operations at the current time until we are “confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.” The ACS calls on surgeons to take a leadership role in their practice settings so that these recommendations can begin to take effect immediately.

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    Number 14
    WHEN CAN PATIENTS SAFELY DRIVE AFTER SURGERY FOR DISTAL RADIUS FRACTURES?
    Author: Anthony Sapienza, MD
    Originally published November 27, 2017

    A major concern for patients following distal radius fracture fixation is when they can resume driving. This decision has medical, legal, and safety considerations, but there are no evidence-based guidelines to assist the surgeon.

    Prior publications have examined functional ability to drive on a simulated course using different types of casts, but no studies had prospectively collected observed driving data on patients after postoperative fixation of distal radius fractures. This is the subject of the study by Jones et al, who sought to determine when these patients are capable of safely resuming driving.

    Patients enrolled in the study underwent a driving examination 2 weeks after surgery for volar plating of a distal radius fracture, with follow-up evaluations at 4 and 6 weeks if the patient failed the preceding examination. 

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    Number 13
    TIPS FOR PREVENTING TIBIAL LOOSENING IN TOTAL KNEE ARTHROPLASTY
    Originally published November 4, 2019

    Aseptic tibial loosening is the number 1 cause of failure leading to revision after total knee arthroplasty (TKA).

    That shouldn’t be the case: At the 7th Annual ICJR South Hip & Knee Course, Daniel J. Berry, MD, from Mayo Clinic in Rochester, Minnesota, said that surgeons know more now about how to cement knee implants than they did even 15 years ago and have – theoretically – gotten better at it.

    But the data suggest, he said, that surgeons have actually become worse at cementing knee implants. They’re rushing through the procedure, he said, using the wrong type of cement and the wrong cementing technique.

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    Number 12
    AN UPDATE ON DVT PROPHYLAXIS FOR TOTAL JOINT ARTHROPLASTY PATIENTS
    Originally published August 2, 2018

    Orthopaedic surgeons have known since the earliest days of arthroplasty that patients undergoing elective joint replacement surgery are at risk for deep vein thrombosis (DVT). Dr. John Charnley, the father of total hip arthroplasty, reported a 2.3% rate of fatal pulmonary embolism (PE) in his patients who had not received DVT prophylaxis, compared with 0.3% in those who had.

    Today, unfortunately, DVT and PE remain an issue for total knee and total hip arthroplasty patients: The readmission rate for DVT and PE after joint replacement surgery is between 5% and 14%, adding to patient morbidity and the cost of the episode of care.

    Balanced against the need for prophylaxis to prevent a catastrophic complication is the understanding that a too-aggressive protocol for DVT prophylaxis will put the joint replacement patient at risk for bleeding, hematoma, and wound issues – which could lead to a perioprosthetic joint infection.

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    Number 11
    ABDUCTOR MECHANISM DEFICIENCY AFTER TOTAL HIP ARTHROPLASTY
    Authors: Nicholas J. Clark, MD, and Rafael J. Sierra, MD
    Originally published November 6, 2017

    Abductor mechanism deficiency after total hip arthroplasty (THA) is a challenging problem. It is most commonly observed after anterolateral approach THA, direct lateral approach THA, and revision THA. The frequency of abductor deficiency varies in different patient populations, ranging from 1% after primary THA done through an anterolateral approach to as high as 21% in patients undergoing revision THA for instability.

    Abductor deficiency generally presents as 3 distinct clinical scenarios:

    • The patient presents with moderate abductor deficiency and limp, often with some lateral hip pain, but without THA instability. This most commonly is seen after THA performed through an anterolateral approach, with a failed abductor tendon and/or muscle repair.
    • The patient presents with severe abductor-related Trendelenburg limp with varying degrees of pain. This may occur in patients with either trochanteric avulsion fracture or complete avulsion of the abductor mechanism from the bone. A common scenario is the patient with severe adverse local soft-tissue reaction due to metal ions with muscle necrosis.
    • The patient presents with recurrent dislocations of the hip in association with abductor deficiency. In cases in which there is no apparent etiology for the dislocation, abductor muscle necrosis often seen in cases with severe taper corrosion should be investigated.

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