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    The Top 10 Clinical Reports of 2018

    More than 1300 clinical reports have been published on ICJR.net since 2013, addressing issues in hip and knee replacement, shoulder surgery, sports medicine, and orthopaedic trauma. Which ones made our list of the 10 most-accessed clinical reports of 2018? Find out below!

    No. 1: An Update on DVT Prophylaxis for Total Joint Arthroplasty Patients
    Originally published on 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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    No. 2: TKA Stiffness: Prevention Is the Best Medicine
    Originally published on 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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    No. 3: Povidone-Iodine Irrigation as a Safe and Effective Measure to Prevent SSIs
    Originally published on July 12, 2018

    A surgical site infection (SSI) after total knee arthroplasty 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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    No. 4: Helping Patient Reduce Their Risks Before Total Joint Arthroplasty
    Originally published on 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

    The stress of surgery antagonizes insulin, predisposing total joint arthroplasty patients – diabetics and non-diabetics alike – to hyperglycemia, which puts them at risk for infection and other complications. The goal, Dr. Springer said, is to maintain the glucose level at less than 200 mg/dL perioperatively.

    What about preoperatively? The best marker of glycemic control is controversial, as the optimum hemoglobin A1C level for surgery is unclear. When a patient’s high hemoglobin A1C is trending downward preoperatively, the magnitude of the decrease may be more relevant to the decision on whether to operate than an arbitrary number, Dr. Springer said.

    The latest test for preoperative glycemic control, Dr. Springer said, is the serum fructosamine level, a simple and inexpensive test that may be a better indicator than hemoglobin A1c.

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    No. 5: 10 Simple Rules for THA After Hip Fracture Fixation
    Originally published on November 15, 2018

    Between 8% and 11% of patients who undergo open reduction and internal fixation (ORIF) for a hip fracture are subsequently converted to a total hip arthroplasty (THA) due to complications of the screw fixation. Conversion from ORIF to THA is a more demanding, technically difficult procedure than an elective primary THA, but it is one that orthopaedic surgeons may need to perform more frequently in the next 20 years as the US population ages and becomes more vulnerable to hip fracture.

    At the meeting, Essential Hip Topics: Cradle to Grave, Ronald E. Delanois, MD, from The Rubin Institute for Advanced Orthopedics in Baltimore, Maryland, shared the rules he follows to improve outcomes in hip fracture patients who are converted to THA.

    Keep comorbidities in mind. Identify and optimize patients’ comorbidities, such as diabetes mellitus and dementia, to improve the quality of care and reduce readmissions.

    Consider the fracture pattern. What was the initial fracture type and fixation, and why did this fixation fail? The answers will impact selection of the prosthesis and fixation of the femoral component.

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    No. 6: Evaluating and Managing Flexion Instability after TKA
    Originally published on October 8, 2018

    In 1993, Arlen D. Hanssen, MD, and David G. Lewallen, MD, noticed a phenomenon among total knee arthroplasty 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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    No. 7: The Jury’s Still Out on These Intraoperative Measures in TJA
    Originally published on August 27, 2018

    Is it time to abandon the time-honored traditions of using drains and tourniquets in total knee arthroplasty patients?

    Maybe for one and not the other, maybe for both, or maybe for neither of them: Surgeons can find studies that support and refute both practices, said Michael J. Taunton, MD, from Mayo Clinic in Rochester, Minnesota, at ICJR’s annual Winter Hip & Knee Course. His presentation was part of a series of lectures on urban legends in total joint arthroplasty.

    Drains

    Surgeons who use drains do so because, they say, the drains decrease hematoma formation, infection risk, and stiffness. But there are potential downsides as well, including increased pain, infection risk, stiffness, and blood transfusion.

    Dr. Taunton quoted a prospective, randomized study from 1994 that looked at the use of drains in 415 total joint arthroplasty patients. The study authors found no statistical difference in wound drainage, transfusion rate, hemoglobin, or range of motion with or without the use of drains.

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    No. 8: Busting Myths about Postop Management of TJA Patients
    Originally published on August 30, 2018

    With his kids providing inspiration through their love of the television show Myth Busters, James A. Browne, MD, has taken a scientific approach to evaluating various practices followed in the postoperative period and determining if they are myths, plausible but need more evidence, or confirmed. He shared his conclusions at ICJR’s annual Winter Hip & Knee Course during a session on urban legends in total joint arthroplasty.

    Dr. Browne, from the University of Virginia in Charlottesville, addressed these issues:

    • Cryotherapy
    • Continuous passive motion
    • Dressing changes
    • Mechanical deep vein thrombosis prophylaxis
    • Flying after surgery
    • Dental prophylaxis

    What did he find? Only mechanical DVT prophylaxis has been confirmed through high-quality evidence, while more research is needed on cryotherapy and dental prophylaxis. Continuous passive motion, dressing changes, flying after surgery – they’re myths he has busted through his review of the literature.

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    No. 9: Reducing Tourniquet Use in TKA as a Pain Management Strategy
    Originally published on April 5, 2018

    Orthopaedic surgeons have been identified one of the top prescribers of opioids. So in the midst of a national conversation around the opioid epidemic in the US, it makes sense that innovative strategies to help reduce pain after joint replacement surgery – and, thus, reduce reliance on opioid pain-relieving medications – are being proposed.

    One such strategy is multimodal pain management, which is already well ingrained in the management of joint replacement patients. And it’s working: A study presented at the 2017 meeting of the American Society of Anesthesiologists showed that between 2006 and 2014, opioid use in patients recovering from hip and knee arthroplasty decreased by one-third. The authors attributed this to the adoption of multimodal pain management protocols.

    What else can orthopaedic surgeons do to reduce opioid use in joint replacement patients? Is there some other way to decrease pain that would, in turn, decrease opioid use?

    There just might be, according to Ran Schwarzkopf, MD, MSc, from NYU Langone Orthopaedic Hospital. He and his colleagues are poised to examine the possibility of eliminating – or at least greatly reducing – the use of tourniquets in primary total knee arthroplasty procedures. The thinking is that postoperative thigh pain from tourniquet use may be contributing to the need for pain medication. Eliminating that source of pain could reduce the use of opioids.

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    No. 10: Why Did These TKAs Fail?
    Originally published on August 6, 2018

    Understanding the variety of failure modes for total knee arthroplasty (TKA) will help the orthopaedic surgeon diagnose and recommend appropriate treatment when a patient complains of pain or other issues following a primary procedure. It can also help the surgeon avoid complications in the future.

    At ICJR’s Winter Hip & Knee Course, Bryan D. Springer, MD, from OrthoCarolina in Charlotte, North Carolina, moderated a case-based panel discussion that featured 5 failed TKAs. Faculty presented their cases, solicited feedback from the panel members, and then revealed how the cases resolved.

    As our panel demonstrated, even the most experienced orthopaedic surgeons have patients whose knee replacements fail.

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