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    The ICJR Top 50: Numbers 40 to 31

    Continuing our countdown of the most-accessed content on ICJR.net with number 40 through number 31.

    Number 40
    PAIN MANAGEMENT IN TKA: PERIARTICULAR INJECTIONS AND PERIPHERAL NERVE BLOCKS
    Authors: Alexander Gaukhman, MD; Simon Garceau, MD; Ran Schwarzkopf, MD, MSc; and James Slover, MD, MS
    Originally published January 23, 2020

    Strategies for pain control following total knee arthroplasty (TKA) have significantly evolved over the last 3 decades:

    • The 1980s saw a rise in the use of intramuscular injections of narcotics.
    • In the 1990s, the patient-controlled analgesia pump was often the modality of choice for managing postoperative pain.
    • By the 2000s, surgeons had shifted toward protocols that minimized the use of opioids, driven in part by early rehabilitation protocols and faster discharge from the hospital.

    Today, most multimodal pain control regimens include a combination of oral medications, periarticular injection (PAI) of anesthetics and/or analgesics, and selective motor-sparing nerve blocks.

    Peripheral nerve blocks (PNB) are commonly used in TKA for adjunctive analgesia. Sensory innervation of the knee originates anteriorly from the femoral nerve and posteriorly from the posterior cutaneous nerve of the thigh emanating from the sciatic nerve. In addition, variable contributions from the saphenous nerve and the lateral femoral cutaneous nerve provide sensory innervation to the medial and lateral aspects of the knee, respectively. These nerves and their respective tributaries are common targets for peripheral nerve blockade.

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    Number 39
    GLENOID BONE LOSS IN PRIMARY RTSA: MANAGEMENT OPTIONS AND OUTCOMES
    Authors: Andrew R. McNamara, MD; Rowan J. Michael, MD; Thomas W. Wright, MD; Bradley S. Schoch, MD; and Joseph J. King III, MD
    Originally published May 10, 2018

    Reverse total shoulder arthroplasty (RTSA) has provided a reliable reconstruction option for older patients with a deficient rotator cuff and glenohumeral osteoarthritis. The reverse prosthesis is a semi-constrained implant, and unlike implants used for an anatomic total shoulder, it does not rely on rotator cuff soft tissue balancing for success. 

    Despite this advantage, reverse prosthesis implantation remains challenging in patients with glenoid bone loss. This article reviews the treatment options for bone loss when performing RTSA.

    Initial evaluation includes plain radiographs of the affected shoulder. The Grashey view should be evaluated for joint space narrowing, acromio-humeral distance (<7mm considered evidence of chronic, irreparable rotator cuff deficiency), and glenohumeral subluxation. The axillary view is particularly helpful to assess glenoid morphology. 

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    Number 38
    ACETABULAR EXPOSURE IN THE EFFICIENT DIRECT ANTERIOR THA
    Authors: Kristoff Corten, MD, PhD, and Jens Vanbiervliet, MD
    Originally published on February 26, 2018

    The efficient direct anterior (EDA) total hip arthroplasty (THA) is a systematic and reproducible hip replacement procedure that can be done on a regular operating room (OR) table. The EDA intra-capsular technique relies on a stepwise capsular exposure followed by 3 sequential capsulotomies, allowing for adequate acetabular exposure and proper femoral elevation.

    In this article, we review the stepwise surgical technique. First, some background and the rationale for the soft tissue, which is the most challenging part during the learning curve.

    A stepwise and systematic procedure is often the key to reproducibility, especially for surgeons in the learning curve. For the anterior approach, the learning curve is estimated to be between 20 and 50 cases, which is not insignificant for a surgeon who averages only a few THAs per month.

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    Number 37
    INSIGHTS ON STIFFNESS AFTER TOTAL KNEE ARTHROPLASTY
    Originally published on January 28, 2019

    Why do some total knee arthroplasty (TKA) patients develop knee stiffness after surgery, and what can be done to manage it?

    Preoperative range of motion (ROM) plays a role: A study published in 2004 found that patients with preoperative stiffness were more likely to have postoperative stiffness.

    But that’s just 1 factor of many possibilities, according to Raymond H. Kim, MD, who reviewed the etiology, diagnosis, and treatment of postoperative knee stiffness at the 6th Annual ICJR South Hip & Knee Course.

    Dr. Kim, from The Steadman Clinic in Vail, Colorado, said a complicating issue is that the definition of “stiffness” is not clear cut. In general, “stiffness” means motion restriction in the operated knee that limits daily function. One study reported a prevalence of 1.3% at 32 months after primary TKA, with stiffness defined for the study as flexion contracture of 15° or more and/or flexion of less than 75°.

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    Number 36
    FEATURED SURGERY: PRIMARY DAA THA USING A MINIMALLY INVASIVE TECHNIQUE
    Originally published March 27, 2018

    John L. Masonis, MD, from OrthoCarolina, Charlotte, North Carolina, performs a primary total hip arthroplasty utilizing the direct anterior approach in a procedure that was broadcast live to attendees at ICJR’s 6th Annual Direct Anterior Approach Hip Course last year.

    The patient is a 58-year-old man with a BMI of 30. He is muscular, with a prominent tensor muscle belly in the affected left hip. Dr. Masonis says the patient has close to a Dorr type A femur, and for that reason, he has templated for an anatomic cementless stem (MiniMAX; Medacta USA, Chicago, Illinois) that will proximally load the femur.

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    Number 35
    SURGICAL REPAIR OF A PROXIMAL HAMSTRING INJURY
    Authors: Anant Dixit, MD, and Steven B. Cohen, MD
    Originally published January 16, 2019

    As a common injury occurring in athletes, hamstring strains are a result of eccentric muscle contraction with the hip flexed and the knee extended. In athletes, this is often manifested during non-contact activities such as sprinting or ballistic movements. Acute strains most often occur at the myotendinous junction.

    The hamstring muscle group includes the semimembranosus, semitendinosus, and biceps femoris (long and short heads) and is innervated by the tibial portion of the sciatic nerve. With the exception of the short heads of the biceps femoris, this muscle group shares a common origin at the ischial tuberosity, separating 5 to 10 cm distal to the ischium. The semimembranosus has multiple insertions on the posteromedial corner of the tibia. The semitendinosus forms the pes anserine with the gracilis and sartorius tendons and attaches on the anteromedial aspect of the proximal tibia. The short head of the biceps, which is innervated by the peroneal branch of the sciatic nerve, originates on the posterior aspect of the distal femur, medial to the linea aspera, and along with the long head of the biceps, attaches to the posteolateral corner of the knee.

    Together, the hamstring tendons contribute to flexion of the knee and extension of the hip. Beyond this, they contribute to the rotatory stability of the knee: the semimembranosus and semitendinosus medially rotate the tibia at the knee and the biceps femoris contributes to lateral tibial rotation at the knee.

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    Number 34
    IS SHOULDER REPLACEMENT REALLY RISKIER THAN PREVIOUSLY THOUGHT?
    Contributors: Leesa M. Galatz, MD; Joseph A. Abboud, MD; Eric M. Padegimas, MD; Jonathan D. Barlow, MD; and Robert U. Hartzler, MD, MS
    Originally published June 3, 2019

    An article recently published in The BMJ on shoulder replacement surgery has generated significant “buzz” online, having been picked up by major news outlets in the US and the UK, blogs, and social media. Alarming headlines have hinted that shoulder replacement is “riskier” than previously thought.

    Have the authors of this study found something new and damning about shoulder replacement surgery? Or has this article been over-hyped?

    To find out, ICJR asked experienced shoulder surgeons to comment on the study findings, its generalizability to shoulder replacement populations outside the UK, and the conversations surgeons should be having with their patients.

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    Number 33
    STEM SELECTION IN CEMENTLESS PRIMARY TOTAL HIP ARTHROPLASTY
    Originally published January 21, 2019

    Most total hip arthroplasty patients in the US undergo a cementless procedure. So, the issue for their surgeons isn’t which type of fixation – cemented or cementless – but rather which type of stem they’re going to use.

    In most cases, the answer will be a proximally porous coated stem, Wayne G. Paprosky, MD, said at the recent ICJR East ISK Hip & Knee Course. Dr. Paprosky, from Rush University Medical Center in Chicago, Illinois, noted that development of this type of stem has grown significantly over the past 10 years compared with development of fully porous coated stems.

    One of the issues with fully porous coated stems is their association with stress shielding in the proximal femur, which can lead to bone resorption. This may not be clinically relevant, Dr. Paprosky said, but it can cause challenging revision surgeries – which is why surgeons have moved away from fully porous coated stems in most situations.

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    Number 32
    HIP ARTHROSCOPY AND CAPSULAR CLOSURE FOR A LABRAL TEAR WITH FAI
    Authors: Anant Dixit, MD; Sundeep Saini, DO; and John P. Salvo Jr., MD
    Originally published September 11, 2019

    Femoroacetabular impingement (FAI) describes the pathologic articulation between the acetabular rim and the femoral head-neck junction. FAI is implicated in the development of hip labral tears. If left untreated, it can lead to progression to hip osteoarthritis. Advancements in hip arthroscopy have allowed for the reliable and effective treatment of FAI, resulting in an increase in rates of arthroscopic hip surgery.

    FAI is marked by subtle anatomic abnormalities that lead to increased mechanical loading during hip range of motion. More specifically, FAI can be classified into 3 morphologic subcategories:

    • CAM-type deformities
    • Pincer-type deformities
    • Mixed-type deformities

    A CAM-type deformity is a femoral-based disorder characterized by a decreased femoral offset at the head-neck junction. The impingement of the aspherical femoral head causes repetitive microtrauma to the otherwise normal acetabular rim and labrum as it prematurely enters the hip joint during range of motion. This results in a characteristic “inclusion-type” delaminating injury to the chondral surface with concomitant labral tearing at the transition-zone cartilage. Intraoperative findings have demonstrated a higher prevalence of CAM-type deformities in male patients compared with female patients (94.6% vs 84.5%), and a corresponding decrease in flexion, internal rotation, and external rotation.

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    Number 31
    WHY LEG LENGTH DISCREPANCY AFTER THA MATTERS – AND HOW IT CAN BE PREVENTED
    Originally published October 17, 2019

    One of the keys to a successful total hip arthroplasty (THA) is restoration of appropriate leg length and offset.

    Why does this matter? At the 7th Annual ICJR South Hip & Knee Course, Bryan D. Springer, MD, from OrthoCarolina Hip & Knee Center in Charlotte, North Carolina, gave 3 very good reasons:

    • Leg length discrepancy is a common cause of patient dissatisfaction after THA.
    • Leg length discrepancy has been found to cause poorer functional outcomes after THA.
    • Leg length discrepancy is the leading cause of litigation after THA.

    What can the surgeon do to prevent leg length discrepancy? Dr. Springer broke it down into preoperative, intraoperative, and postoperative interventions.

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