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    The ICJR Top 50: Numbers 50 to 41

    This week, we count down the most-accessed content of all time on ICJR.net, starting with number 50 through number 41.

    Number 50
    TECHNIQUES FOR OPTIMIZING ACETABULAR COMPONENT POSITIONING IN THA
    Authors: James E. Feng, MD; Afshin A. Anoushiravani, MD; Nima Eftekhary, MD; Jonathan Vigdorchik, MD; and Ran Schwarzkopf, MD, MSc
    Originally published June 7, 2018

    Ideal and accurate acetabular component positioning in total hip arthroplasty (THA) remains a challenge. It is estimated that newly fellowship-trained arthroplasty surgeon must perform 50 consecutive THAs to achieve a satisfactory level of surgical competency. Even for the experienced surgeon, between 39% and 50% of acetabular cup placements fall outside the Lewinnek abduction and/or anteversion safe zones

    Moreover, poor component positioning is the most significant risk factor for hip instability and excessive early liner wear. Other complications of poor component positioning include:

    • Impingement
    • Shell-liner dissociation
    • Leg-length discrepancy
    • Limited range of motion (ROM)
    • Osteolysis
    • Hardware squeaking in ceramic bearing hips

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    Number 49
    HELPING PATIENT REDUCE THEIR RISKS BEFORE TOTAL JOINT ARTHROPLASTY
    Originally published October 1, 2018

    Patients scheduled for total joint arthroplasty can have dozens of risk factors for complications after surgery. In his presentation at ICJR’s 6th Annual ICJR South Hip & Knee Course, Bryan D. Springer, MD, from OrthoCarolina Hip & Knee Center in Charlotte, North Carolina, focused on 7 common modifiable risk factors surgeons can address to help their patients reduce the chances of developing serious, potentially life-threatening complications:

    • Glycemic monitoring
    • Obesity
    • Malnutrition
    • Smoking
    • Vitamin D deficiency
    • MRSA and MSSA screening
    • Management of anti-rheumatic medications

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    Number 48
    FEATURED SURGERY: ROBOTIC-ARM ASSISTED TECHNOLOGY IN PRIMARY TKA
    Originally published February 28, 2018

    Yogesh Mittal, MD, from The Orthopaedic Center in Tulsa, Oklahoma, performs a primary total knee arthroplasty with robotic assistance in a procedure broadcast to attendees at ICJR’s Transatlantic Orthopaedic Congress.

    Dr. Mittal’s patient is a 65-year-old woman with varus deformity evident on radiographs and on examination. She has some flexion contracture and patellofemoral disease. Dr. Mittal’s plan is to use a posterior stabilized knee implant.

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    Number 47
    PROXIMAL TIBIOFIBULAR JOINT RECONSTRUCTION IN A YOUNG EQUESTRIAN
    Authors: Yehuda E. Kerbel, MD; Nimit Patel, MD; and Sommer Hammoud, MD
    Originally published July 11, 2018

    Proximal tibiofibular joint (PTFJ) instability is a rare clinical condition that typically occurs after twisting or pivoting injury on a flexed knee. Despite its infrequent occurrence in clinical practice and scarce discussion in the literature, PTFJ instability has long been recognized as a source of lateral knee pain. It was originally described by Ogden, who classified PTFJ injury into 4 patterns of instability:

    • Atraumatic subluxation, 23.3% of cases
    • Anterolateral dislocation, 67.4% of cases
    • Posteromedial dislocation, 7% of cases
    • Superior dislocation, 2.3% of cases

    Patients with PTFJ instability are often misdiagnosed. They typically present with pain and clunking at the lateral knee as the joint dislocates, with many patients also having numbness in their peroneal nerve distribution. In severe cases, they may even have weakness in ankle dorsiflexion and eversion. The differential diagnosis is wide and includes lateral collateral ligament injury, biceps femoris tendonitis, posterolateral rotatory instability, and hypermobile torn meniscus.

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    Number 46
    HOW SHOULD SURGEONS MANAGE SYMPTOMS OF PSOAS TENDINITIS AFTER THA?
    Author: Michael J. Taunton, MD
    Originally published March 23, 2020

    The iliopsoas muscle originates from the transverse processes of the 12th thoracic vertebrae through the 5th lumbar vertebrae. The musculotendinous portion crosses the anterior acetabulum over the anterior column. The tendon inserts on the lesser trochanter. The muscle is innervated by branches of the femoral nerve and serves in hip flexion.

    Patients experiencing psoas tendinitis after THA typically present with groin pain with activity. The onset of this pain may occur immediately after surgery or in a delayed fashion. The symptoms typically develop with resisted hip flexion activities, such as ascending stairs, getting up out of a chair, and getting in and out of automobiles. Patients who exercise excessively after THA, especially soon after surgery, may also experience groin pain.

    On physical exam, patients have pain with resisted hip flexion or, in some cases, passive hyperextension. There is occasionally a “snap” or a “catch” as the leg is extended. The hip is typically painless throughout the remainder of passive range of motion. Patients may also have tenderness when palpated on the anterior aspect of the hip. Neurologic findings, such as numbness or weakness in other muscle groups, are atypical, and if present, suggest that other diagnoses should be investigated.

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    Number 45
    SELECTING PATIENTS FOR OUTPATIENT SURGERY: A NOVEL SCORING SYSTEM
    Originally published February 25, 2019

    Which patients are appropriate candidates for outpatient joint replacement?

    That question is at the heart of the Outpatient Arthroplasty Risk Assessment (OARA) Score, which was developed by R. Michael Meneghini, MD, and his colleague at Indiana University School of Medicine in Indianapolis, Peter Caccavallo, MD, MS, a perioperative medicine specialist.

    The OARA score was conceived as an alternative to the American Society of Anesthesiologists (ASA) score typically used to evaluate patients’ physical status before surgery. However, the ASA score lacks the sensitivity and specificity for determining which patients can safely undergo an outpatient procedure, Dr. Meneghini said in a presentation at ICJR’s Winter Hip & Knee Course.

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    Number 44
    CHALLENGING THE LEWINNEK SAFE ZONE
    Authors: Emilie R. C. Williamson, MD, and Ajit J. Deshmukh, MD
    Originally published March 18, 2019

    Several studies have reported that placing the acetabular cup in the Lewinnek safe zone – a parameter of acetabular inclination and anteversion in the coronal plane on standing pelvic radiographs – does not ensure hip stability in total hip arthroplasty (THA) patients. The acetabular inclination (40° 10°) and anteversion (15° 10°) indicated in the Lewinnek safe zone is not representative of cup changes during functional activities such standing from a sitting position, which may be measured on lateral sitting and standing radiographs.

    The change in cup position, rotating in the sagittal plane, is directly related to spinopelvic motion:

    • The pelvis tilts anteriorly while standing, allowing the acetabulum to cover the femoral head.
    • The pelvis tilts posteriorly while sitting, allowing the acetabulum to open in anteversion and permit clearance of the femur.

    If there is spinopelvic imbalance, the resulting cup positions may not keep the cup within the Lewinnek safe zone.

    In a prospective, cohort, observational radiographic study, Tezuka et al sought to determine if acetabular cups implanted within the Lewinnek safe zone are always concomitantly within the functional safe zone as defined by the combined sagittal index (CSI), which is equal to the sum of the anteinclincation (AI) and pelvic femoral angle (PFA).

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    Number 43
    TKA STIFFNESS: PREVENTION IS THE BEST MEDICINE
    Originally published September 18, 2018

    Stiffness is one of the primary reasons for patient dissatisfaction with their total knee arthroplasty (TKA). Because stiffness is a challenge to manage, the best treatment option is to prevent it from occurring in the first place, says Raj K. Sinha, MD, PhD, from STAR Orthopaedics in Rancho Mirage, California.

    Speaking at ICJR’s annual Winter Hip & Knee Course, Dr. Sinha said the problem is that all patients are potentially at risk, and it is difficult to predict which ones will develop stiffness and which ones won’t.

    He said that all patients have some modifiable and/or non-modifiable risk factors for stiffness after TKA, such as age, smoking, and prior surgeries. They’re further at risk just from the surgery itself, as errors in the surgical technique – including malpositioning the implant, overstuffing the anterior compartment, and an implant that’s the wrong size (too big or too small) – can lead to stiffness.

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    Number 42
    OPTIONS FOR DEALING WITH POSTERIOR GLENOID BONE LOSS IN ANATOMIC TSA
    Authors: Michael Priddy, MD; Brad S. Schoch, MD; Thomas W. Wright, MD; and Joseph J. King, MD
    Originally published June 28, 2018

    Total shoulder arthroplasty (TSA) has been shown to provide lasting pain relief and good long-term implant survival in many patients. Using first-generation total shoulder implants, Torchia et al demonstrated a 93% survival rate at 10 years and an 87% survival rate at 15 years. Similarly, 83% of patients had significant pain relief after TSA.

    However, certain patient populations may not do as well with a standard anatomic TSA. Iannotti et al showed that patients with preoperative posterior subluxation had lower ASES scores, more pain, and less external rotation than patients without subluxation. Glenoid version affects not only posterior subluxation and posterior loading, but also glenoid component loosening. Fifteen degrees of retroversion has been shown to decrease contact area, increase contact pressure, and decrease inferior and posterior glenohumeral forces in TSA.

    Multiple strategies can be used to reduce the negative effects of glenohumeral retroversion and/or posterior subluxation in TSA. For example, eccentric reaming, bone grafting, and augmented glenoid components are intended to allow placement of an anatomic total shoulder implant in patients with significant glenoid wear. In more severe cases of glenoid wear, the surgeon can consider 2-stage TSA with glenoid bone grafting, the “ream and run” procedure, or the use of a reverse total shoulder arthroplasty with a glenoid baseplate, depending on the clinical picture and degree of bone loss.

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    Number 41
    THE ROLE OF DUAL MOBILITY IMPLANTS IN REDUCING INSTABILITY IN PRIMARY THA
    Originally published August 29, 2019

    Dual mobility implants are typically thought of as an option for reducing recurrent dislocations in patients undergoing revision total hip arthroplasty (THA).

    But there is a growing list of indications for the dual mobility constructs in primary THA, according to Matthew P. Abdel, MD, who spoke on the topic at ICJR’s 11th Annual Winter Hip & Knee Course.

    Dr. Abdel, from Mayo Clinic, Rochester, Minnesota, will consider dual mobility implants in primary THA patients with at least a 5% risk for recurrent dislocations due to:

    • Femoral neck fractures
    • Conversion THAs
    • Oncologic reconstructions
    • Cognitive impairment
    • Compromised abductors
    • Lumbar fusion

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