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    The ICJR Top 50: Numbers 30 to 21

    Continuing our countdown of the most-accessed content on ICJR.net with number 30 through number 21.

    Number 30
    WHAT CAUSES A STIFF KNEE AFTER TKA – AND HOW CAN IT BE PREVENTED?
    Author: Jesse E. Otero, MD, PhD
    Originally published May 28, 2020

    The goals of TKA are to relieve pain and restore function in patients with moderate to advanced osteoarthritis who have exhausted conservative treatments but still have knee pain that interferes with their activities of daily living. In most patients’ minds, the ideal result of TKA would be a knee that moves and feels the way it did in a more youthful time.

    Before discussing stiffness after TKA, it is essential to first review normal native knee motion in relation to the activities patients routinely perform. Laubenthal et al [1] presented a quantitative analysis of knee motion required to achieve normal activities of daily living. In this classic article, the authors used an electro-goniometer to show that on average:

    • 83° of flexion is required for climbing stairs
    • 93° of flexion is required for sitting
    • 106° of flexion is required for tying a shoe
    • 117° of flexion is required for squatting to lift an object

    The widely accepted target after TKA, based on this study, is 120° of knee flexion. In objective terms, therefore, knees that fail to achieve 120° of flexion after surgery are commonly considered to be stiff.

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    Number 29
    MANAGEMENT OF HILL-SACHS LESIONS
    Authors: Felix H. Savoie III, MD, and Michael O’Brien, MD
    Originally published January 13, 2014

    The Hill-Sachs defect is a compression fracture of the humeral head associated with instability. At the time of shoulder dislocation, the soft cancellous bone of the humeral head is impressed against the hard cortical bone of the anterior glenoid rim, creating a compression fracture in the humeral head. This can be visualized on an internal rotation radiograph of the shoulder, as first described by Hill and Sachs in 1940.

    The incidence of the defect approaches 100% in patients with recurrent anterior shoulder instability. Larger lesions with advanced bone loss are more likely to engage, resulting in shoulder instability at lower arm abduction angles. In patients with moderate bone loss, the defect may be managed by arthroscopically filling in the defect with the infraspinatus tendon or with allograft corticocancellous plugs.

    Arthroscopic management of these defects includes:

    • Transfer of the infraspinatus and posterior capsule into the defect, known as the remplissage procedure
    • Bone grafting of the defect with allograft humeral or femoral head
    • Replacement

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    Number 28
    TROCHANTERIC OSTEOTOMIES IN REVISION THA: INDICATIONS AND SURGICAL TECHNIQUES
    Authors: Ryan S. Charette, MD; Wayne G. Paprosky, MD; and Neil P. Sheth, MD
    Originally published December 7, 2017

    Total hip arthroplasty (THA) is a well-tolerated surgical procedure that reduces pain and improves functional status, offering patients with end-stage degenerative joint disease a better health-related quality of life. Medium- and long-term data have shown a high percentage of patients retain a well-functioning prosthesis. This success has led to an expansion of indications to younger and more active patients and with it, projections that the rate of both primary and revision THA will continue to increase exponentially over the next 2 decades.

    Although trochanteric osteotomy is rarely done with a primary THA, revision procedures may require advanced techniques to enhance exposure. Historically, the Wagner osteotomy was described as an anterior proximal femoral osteotomy. Other more-common osteotomies about the greater trochanter include the standard (trochanteric flip), slide, and extended trochanteric osteotomy (ETO).

    This review presents an overview of the indications, contraindications, and technical pearls for these most common osteotomies, with a focus on ETO.

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    Number 27
    HOW TO EVALUATE VARUS AND VALGUS DEFORMITY OF THE KNEE
    Originally published March 4, 2020

    Instability accounts for 25% of revision total knee arthroplasty (TKA), making it one of the most common reasons for early and late revision procedures.

    That’s why it’s so important for surgeons to address varus or valgus deformity during the index surgery, Matthew P. Abdel, MD, told attendees at ICJR’s inaugural course for senior residents and fellows, Advanced Techniques in Total Hip & Knee Arthroplasty, whether they use cruciate retaining or posterior stabilized implants. Otherwise, the patient has a strong chance of requiring revision TKA.

    During his presentation, Dr. Abdel, from Mayo Clinic in Rochester, Minnesota, reviewed how he categorizes the amount of varus or valgus deformity and described how he alters his surgical technique to accommodate the deformity.

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    Number 26
    VIDEO TECHNIQUE: EXTENSILE EXPOSURE WITH THE WAGNER TRANSFEMORAL OSTEOTOMY
    Originally published September 27, 2018

    The Wagner transfemoral osteotomy – in which the anterior one-third of the femur is osteotomized – is just 1 type of osteotomy that surgeons have in their toolbox for revision total hip arthroplasty, Michael. J. Taunton, MD, said at the start of his presentation at ICJR’s 6th Annual Revision Hip & Knee Course. Which osteotomy they use for extensile exposure will depend on the situation.

    For example, Dr. Taunton, from Mayo Clinic in Rochester, Minnesota, showed cases examples of patients with extensive proximal osteolysis and noted that the Wagner transfemoral osteotomy was more appropriate for these patients than an extended trochanteric osteotomy (ETO). If he had performed an ETO, he said, the bones may have crumbled.

    The Wagner transfemoral osteotomy is a versatile osteotomy, Dr. Taunton said, but surgeons who utilize it must decide they’re going to do the Wagner osteotomy as they’re making their approach, unlike an ETO. Performing an anterolateral approach and then the Wagner osteotomy would have the undesirable consequence of devitalizing the anterior bone, he said.

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    Number 25
    IS THERE A PREFERRED POSITION FOR ARTHROSCOPIC ROTATOR CUFF REPAIR?
    Authors: Michael J. Bender, MD, and Brent J. Morris, MD
    Originally published April 16, 2018

    Rotator cuff tears are one of the most common shoulder problems treated by orthopaedic surgeons. As surgeons have transitioned from open to arthroscopic techniques to treat most shoulder pathology, there has been spirited debate over the superiority of lateral decubitus or beach chair positioning for various procedures. Most surgeons determine patient positioning based on their training and comfort level, but there are some distinct differences between the 2 positions.

    Lateral decubitus positioning: The patient is placed in the lateral decubitus position on a standard operating room bed with the operative extremity up. A beanbag or other commercial positioner stabilizes the patient; the use of an axillary roll and judicious padding of bony prominences and superficial nerves is crucial to prevent pressure ulcers or nerve complications. A lateral traction device holds the arm in an abducted position, typically with 10 to 15 pounds of traction.

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    Number 24
    CALCIFIC TENDINITIS OF THE SUBSCAPULARIS TENDON
    Authors: Richard McEntee, BS, and Daniel Davis, MD, MS
    Originally published May 18, 2019

    Calcific tendinitis of the rotator cuff is caused by deposition of calcium in and around the tendons of the rotator cuff. It is a relatively common cause of shoulder pain, estimated to occur in 2.5% to 7.5% of adults. There is a gender predisposition to calcific tendonitis, with 70% of all cases occurring in women, and the majority of patients are age 40 to 60 years old.

    Although the presence of calcific tendinitis of the rotator cuff is common, only 35% to 50% of patients are symptomatic. Rotator cuff calcific tendinitis does not affect the muscles of the rotator cuff in equal proportion. Estimates of the frequency of calcific tendinitis involving the subscapularis tendon range from 5% to 10%, while 15% to 30% of cases involve the infraspinatus tendon and 51% to 82% involve the supraspinatus tendon.

    In this article, we report on a case of subscapularis tendinitis.

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    Number 23
    EXTENDED ANTIBIOTIC PROPHYLAXIS CAN REDUCE PJIs IN REVISION TKA PATIENTS
    Author: Susan Doan-Johnson
    Originally published June 6, 2019

    In a study published at the end of last year, R. Michael Meneghini, MD, and his colleagues from the Indiana University School of Medicine reported that high-risk primary total knee arthroplasty (TKA) patients who took antibiotics for 7 days after surgery were nearly 5 times less likely to develop a periprosthetic joint infection (PJI) than patients who did not take antibiotics postoperatively.

    They concluded that this protocol of extended antibiotic prophylaxis resulted in a “statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection.”

    They also wondered: Would the same be true of revision TKA patients?

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    Number 22
    DOES THE SURGICAL APPROACH AFFECT THE PJI?
    Authors: Nolan A. Maher, MD, and William J. Long, MD, FRCSC
    Originally published September 17, 2019

    Recent studies have examined the rates of wound complications and infection associated with the direct anterior versus the posterior approach, with mixed results: Some studies have demonstrated an increased risk of surgical site infection with the anterior approach, while others have shown no significant differences.

    The study by Aggarwal et al used a larger cohort of patients than previous studies to evaluate the risk of periprosthetic joint infection (PJI) in patients undergoing primary total hip arthroplasty (THA) utilizing the direct anterior approach versus all other surgical approaches.

    This single-center study identified a cohort of 6086 patients who underwent primary THA between 2013 and 2016. The direct anterior approach was utilized in 1985 cases; other approaches to the hip were used in 4101 patients. The primary endpoint of the study was the diagnosis of PJI within 90 days of surgery, based on established criteria from the Centers for Disease Control’s National Healthcare Safety Network (CDC/NHSN).

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    Number 21
    POVIDONE-IODINE IRRIGATION AS A SAFE AND EFFECTIVE MEASURE TO PREVENT SSIs
    Author: Susan Doan-Johnson
    Originally published July 12, 2018

    A surgical site infection (SSI) after total knee arthroplasty (TKA) can result in significant patient morbidity and increased institutional costs. Fortunately, there are intraoperative measures the surgical team can implement to reduce the risk of an SSI. The question is, how effective are these measures in decreasing the number of SSIs? And, are any of them more effective than others?

    Those were the questions surgeons from The Rothman Institute sought to answer in an investigation comparing the effectiveness of 3 intraoperative measures – use of dilute povidone-iodine (Betadine) irrigation, subcuticular monofilament suture instead of skin staples, and occlusive dressings – that were introduced over the last decade at their institution to prevent SSIs.

    Their findings were presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

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