The Top 10 Feature Articles of 2018

    More than 200 articles 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 articles of 2018? Find out below!

    No. 1: What Are the Top Considerations for the Table Used in a DAA THA?
    Authors: Stephen J. Nelson, MD, and Lee E. Rubin, MD
    Originally published on February 5, 2018

    ICJR: Surgeons continue to debate the value of using a special table when performing a direct anterior approach total hip arthroplasty. What factors should they weigh when deciding whether they need a special table?

    Stephen J. Nelson, MD: The supine patient position used in a direct anterior approach (DAA) total hip arthroplasty readily facilitates acetabular exposure and preparation, which allows accurate and consistent cup placement.

    Despite this, elevation of the femur to allow for safe broaching has often been cited as the most difficult part of the DAA. Although the DAA was first described in the US without the assistance of an orthopedic table by Light and Keggi, the Judets adapted an orthopedic traction table specifically to facilitate femoral exposure. Later, Matta popularized the anterior approach by standardizing the steps of the procedure to educate surgeons and ensure reproducibility, and also promoted the use of the Hana table to assist with femoral elevation.


    No. 2: 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 on 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
    • Osteolysis
    • Hardware squeaking in ceramic bearing hips


    No. 3: Antibiotics for Perioperative Prophylaxis in Total Joint Arthroplasty
    Authors: Andrew M. Pepper, MD; Lewis Moss, MD; and Jonathan M. Vigdorchik, MD
    Originally published on July 17, 2018

    Prevention of surgical site infection (SSI) – specifically, prevention of periprosthetic joint infection (PJI) – has been a topic of intense interest in the medical and surgical community for the last 2 decades. The reasons for this are numerous, but the most intense focus is on preventing the devastating medical, surgical, and economic consequences of PJI, which is generally regarded as a “preventable” complication in patients undergoing elective total joint arthroplasty.

    The purpose of this article is to discuss:

    • The history of current standards for perioperative antibiotic therapy for prevention of SSI
    • The recent recommendations from the Centers for Disease Control and Prevention
    • The available literature on the timing and selection of antibiotics
    • The common issue of prophylactic antibiotics for arthroplasty patients undergoing other invasive medical procedures


    No. 4: Safely Transitioning from the Posterior to the Direct Anterior Approach
    Authors: Brian M. Culp, MD, and Hari P. Bezwada, MD
    Originally published on July 19, 2018

    Interest in the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased significantly over the last decade. Surgeons’ familiarity with performing this approach, however, largely depends on their education and experiences, including which approaches they were taught in residency and fellowship and which approaches their practice partners favor.

    Adoption of the DAA can be challenging for surgeons trained in other approaches due to the nuances of exposure and component positioning for the DAA. To avoid putting patients at undue risk during the transition period from another approach, surgeons interested in the DAA, therefore, must commit to re-learning much of what they know about how to perform a THA, including:

    • Techniques for safe exposure
    • Relevant at-risk clinical anatomy not routinely visible via other approaches
    • Implant and special instruments designed for easier preparation and implantation
    • Technologic tools to help with proper component positioning
    • Solutions to complex situations should they arise intraoperatively


    No. 5: The 7 Pillars of Value-Based Care in Total Joint Arthroplasty
    Authors: David Novikov, BS; Joseph A. Bosco III, MD; and Richard Iorio, MD
    Originally published on January 24, 2018

    The cost of healthcare in the US was projected to reach a total of $3.2 trillion as of 2015. This rising liability has sparked interest in medical economics and has prompted the creation of healthcare payment reforms that stress value-based care in an effort to improve the coordination, quality, and cost-effectiveness of care delivered.

    As a product of the Affordable Care Act, the Center for Medicare and Medicaid Innovation first announced the Bundled Payments for Care Improvement (BPCI) initiative in 2011, with the goal of examining the effectiveness of 4 payment models among 48 clinical conditions based on the Medicare Severity-Diagnosis Related Group (MS-DRG). A 3-year voluntary initiative, with an optional institutional 2-year extension, the BPCI program included 3 retrospective payment models that calculated target payments that were discounted and based on historical payments made by the Centers for Medicare and Medicaid Services (CMS) for similar MS-DRG episodes of care (EOC).

    Participants – including surgeon groups and hospitals – received discounted Medicare fee-for-service payments that would then be compared with the set target price. Savings could be gain-shared among the providers if the CMS payments failed to reach the target price. Alternatively, financial risk would fall on the healthcare organization if CMS payments surpassed the target price.


    No. 6: Perioperative Pain Management in TJA: What Should Be in the Mix?
    Authors: Andrew M. Pepper, MD; John J. Mercuri, MD, MA; Omar A. Behery, MD, MPH; and Jonathan M. Vigdorchik, MD
    Originally published on March 22, 2018

    Total joint arthroplasty (TJA) is an inherently painful surgical procedure. Up to 60% of patients who undergo total knee arthroplasty report having severe postoperative pain; another 30% report moderate pain. Optimizing pain control for patients undergoing TJA is not only crucial for patient well-being, but it is also increasingly important in today’s value-based patient care. As such, orthopaedic surgeons need a predictable, evidence-based, and cost-effective protocol for perioperative analgesia that maximizes pain management while minimizing side effects from the analgesics used.

    Adequate pain control has been correlated with faster rehabilitation and improved measures of patient satisfaction, such as health-related quality-adjusted life years, return to work, and overall satisfaction. It is also associated with reduced risk of readmission, a shorter length of stay, and a reduced risk of complications, such as myocardial infarction, pneumonia, venous thromboembolic disease, and chronic pain syndromes. All these advantages synergistically decrease costs and improve the quality of care, thereby increasing the value of the care provided.


    No. 7: 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 is a systematic and reproducible hip replacement procedure that can be done on a regular operating room 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.

    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.

    Therefore, every effort should be made to minimize this learning curve. One strategy to do is to adopt an evidence-based capsular releasing sequence prior to acetabular exposure and femoral elevation. We believe any capsular release should strike a balance between sufficient femoral exposure and minimal violation of the soft tissues.


    No. 8: Distal Tibia Non-union After Seemingly Successful Fracture Reduction
    Author: Brandon J. Yuan, MD
    Originally published on September 24, 2018

    A 48-year-old male patient with a history of nicotine dependence (less than 1 pack per week) presents with a closed extra-articular distal tibia and fibula fracture that occurred in a twisting injury on a wet surface, falling from standing height. No CT scan was obtained, and the patient was taken to the operating room for surgical fixation of this injury.

    Many high-energy distal tibia fractures that require open exposures through the zone of injury warrant consideration for temporary external fixation to restore stability, length, and alignment. This will allow time for the soft tissue swelling associated with the initial trauma to resolve prior to imparting additional surgical trauma to the limb.

    However, the history and radiographs of this injury imply a relatively low-energy mechanism, and the soft tissue envelope may be acceptable for immediate definitive surgical management. In addition, use of a medullary device may be appropriate for this extra-articular injury, allowing for minimal additional soft tissue trauma to the distal leg.


    No. 9: Are Smoking Cessation Programs Effective for Total Joint Arthroplasty Patients?
    Authors: Charity Jacobs, MD; Fernando Nussenbaum, MD; Jonathan Vigdorchik, MD; and Ran Schwarzkopf, MD
    Originally published on November 29, 2018

    According to the most recent data available, approximately 600,000 primary total knee arthroplasty procedures and 310,000 primary total hip arthroplasty procedures are performed yearly in the US, and that number continues to grow.  

    With the rise in primary knee and hip replacements, there has been a concomitant increase in revision procedures, which have higher rates of complications and greater costs to patients, hospitals, and healthcare system. In addition, the advent of bundled payment models for joint replacement surgery has changed the thought process on patient selection for many surgeons. More focus is now being placed on addressing modifiable risk factors that may increase the risk of total joint arthroplasty failure. One such risk factor is smoking.


    No. 10: What Is the Current State of Biologics for Augmenting Rotator Cuff Repairs?
    Author: Raffy Mirzayan, MD
    Originally published on January 15, 2018

    ICJR: What biologics are currently available to augment rotator cuff repair, and what does the literature say about them?

    Raffy Mirzayan, MD: Rotator cuff tears are a frequent cause of shoulder pain and disability. Between 250,000 and 400,000 rotator cuff repairs are performed annually in the United States, creating a significant impact on the healthcare system and on patients’ lives. Rotator cuff repair surgery, regardless of technique – traditional open, mini-open, arthroscopic, single row, double row – results in a high level of patient satisfaction and great clinical outcomes.

    However, imaging studies reveal up to a 94% mechanical failure (“re-tear”) of the repairs. Therefore, most of the current surgical focus is directed at reducing re-tear rates, not clinical improvement.

    Better terminology should be considered to define mechanical failure. As used in the literature, the term “re-tear” implies that the tendon healed to the tuberosity and then tore again. A more universal terminology – such as “structural integrity” rate – should be used in the literature to describe the actual state of the tendon-bone interface.