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    The Top 10 Feature Articles of 2019

    More than 300 feature 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 2019? Find out below!

    No. 1: The Disappearing Stem: The Changing Humeral Side of Shoulder Arthroplasty
    Authors: Jed Maslow, MD; John Paul
    Wanner, MD; Howard Routman, DO; and Ian Byram, MD
    Originally published on February
    21, 2019

    Total shoulder arthroplasty (TSA), like hip and knee arthroplasty, has undergone a major transformation in technique and technology over the last century, driven by a demand for increasing efficiency and improved outcomes. The rate of TSA is increasing by 6% to 13% per year, translating to 5 times as many surgeries performed in 2010 than in 2000. As the popularity of the procedure continues to increase, so does the cost, rising at least $900 per procedure per year.

    Although external factors such as price and policy may have some influence, advances in implants and surgical technique allow surgeons to focus on restoring anatomy, minimizing soft tissue disruption, and planning for possible revision surgery.

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    No. 2: Does the Surgical Approach Affect the PJI Rate in Total Hip Arthroplasty?
    Authors: Nolan A. Maher, MD, and William J. Long, MD, FRCSC
    Originally published on 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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    No. 3: Latissimus Dorsi and Teres Major Tear in a Throwing Athlete
    Authors: Brandon J. Erickson, MD, and Anthony A. Romeo, MD
    Originally published on October 10, 2018

    Injuries to the latissimus dorsi (LD) and teres major (TM) are uncommon problems affecting athletes, specifically those who participate in overhead sports such as baseball. Unfortunately, because these injuries are uncommon, they are often difficult to diagnose and, therefore, are commonly missed, leading to problems with these athletes returning to sport. Treatment for these injuries varies and can involve rest and rehabilitation or surgical repair.

    The LD takes its origin from the lower ribs, iliac crest, and spinous processes of the lower 6 thoracic vertebrae. As it heads towards its insertion on the floor of the intertubercular groove of the humerus, it externally rotates 90° to allow the muscle to work more efficiently. The TM originates on the dorsal surface of the inferior angle of the scapula and inserts on the medial lip of the intertubercular of the humerus. The TM is deep and cranial to the LD. Cadaveric studies have found the LD and TM tendons often coalesce before insertion; occasionally the TM will insert onto the LD.

    The LD and TM are strong internal rotators of the humerus and are most active during the late cocking and acceleration phases of the pitching cycle; they also have a small amount of activation during the deceleration phase. The LD and TM are important structures in the kinetic chain of pitching, whereby the force generated from the lower extremity and trunk is transferred to the humerus and upper extremity. These muscles play a role in protecting the shoulder from excess shear and manufacturing pitch speed.

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    No. 4: MPFL Reconstruction in a Young Athlete
    Authors: Neel A. Gupta, MD; Nimit Patel, MD; and Shyam Brahmabhatt, MD
    Originally published on April 19, 2018

    Recurrent patellar instability continues to be a challenging problem for orthopaedic surgeons, with incidence increasing each year. The rate of patellar dislocation is highest in the 10- to 17-year-old age group, with reported rates of 29% to 43%. In addition, females have a 33% increased prevalence of acute patellar dislocation compared with males.

    Disruption of the medial patellofemoral ligament (MPFL) is thought to be the essential lesion resulting in recurrent patellar dislocation. According to several anatomic and biomechanical studies, the MPFL is the most important restraint to lateral patellar displacement from 0° to 30° of knee flexion. The MPFL is compromised in the vast majority of acute dislocations, and its capacity to heal is limited.

    There is some debate regarding the management of a first-time patellar dislocation. In a randomized controlled trial, Palmu et al and Hennrikus and Pylawka reported no significant difference in long-term subjective or functional results between operative and non-operative treatment of first-time traumatic patellar dislocations. As a result, non-operative treatment continues to be the standard of care for first-time traumatic patellar dislocation, except in cases involving osteochondral fractures, vastus medialis avulsions, large osteochondral fragments, or concomitant intra-articular abnormalities such as meniscal tears.

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    No. 5: Challenging the Lewinnek Safe Zone
    Authors: Emilie R. C. Williamson, MD, and Ajit J. Deshmukh, MD
    Originally published on 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.

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    No. 6: 10 Tips and Tricks for ORIF of Proximal Humerus Fractures
    Authors: Joseph J. King, MD; Corey A. Jones, BS; and Thomas W. Wright, MD
    Originally published on July 20, 2016

    Ensure appropriate operating room setup

    When performing open reduction internal fixation (ORIF) of a proximal humerus fracture, we prefer to place the patient in the lazy beach chair position, with the head of the table elevated to around 30°.  Raising the head of the table any higher would make it more difficult to obtain a Grashey view x-ray.

    The thorax should be situated as close to the edge of the table as possible to allow free access to and mobilization of the shoulder. The patient’s head should be at the top edge of the table to allow for an easier axillary lateral x-ray. The head should be secured to the table with tape to prevent it from falling off the table with shoulder manipulation.

    The fluoroscopy machine should come in from the top of the table after the table has turned 90° so the contralateral side is next to anesthesia.

    We prefer to use a hydraulic limb positioner to help hold the arm during the procedure.

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    No. 7: 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 (CDC)
    • The available literature on the timing and selection of antibiotics
    • The common issue of prophylactic antibiotics for arthroplasty patients undergoing other invasive medical procedures

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    No. 8: Distal Tibia Non-union After Seemingly Successful Fracture Reduction
    Author: Brandon J. Yuan, MD
    Originally published on September 28, 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.

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    No. 9: Periprosthetic Tibial Shaft Fracture after Kinematically Aligned TKA
    Authors: Timothy L. Tan, MD; Keith P. Connolly, MD; and P. Maxwell Courtney, MD
    Originally published on March 20, 2019

    Periprosthetic fractures of the tibia following total knee arthroplasty (TKA) are much less common than periprosthetic femur fractures, with an incidence of around 1%. Risk factors include component malalignment, loosening, and instability, with 1 small series identifying varus positioning of the tibia as a risk factor for periprosthetic fracture.

    Kinematically aligned TKA has become an increasing popular alternative to traditional mechanical alignment, with the goal of matching the native varus of the proximal tibia and native valgus of the distal femur while minimizing soft tissue releases. Although a recent meta-analysis found equivalent results and slightly improved functional outcomes with kinematically aligned TKA compared with mechanically aligned TKA, concerns exist regarding patellar maltracking and long-term survivorship of the prosthesis with a varus tibial component.

    To date, no study has identified an association between kinematic alignment and periprosthetic fractures, but further study is needed.

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    No. 10: Stem Exchange in Revision TKA for Periprosthetic Fracture
    Authors: Joseph A. Karam, MD; David G. Nazarian, MD; and P. Maxwell Courtney, MD
    Originally published on July 18, 2019

    Periprosthetic fractures around a total knee arthroplasty (TKA) present a treatment dilemma for the orthopaedic surgeon. With an aging population and an increase in the number of TKAs being performed worldwide, the incidence of associated periprosthetic femur and tibia fractures continues to rise as well. Classically, however, treatment algorithms have been developed based on the stability of existing knee implants.

    Because most periprosthetic fractures around the TKA implant occur in older patients, pre-existing bone stock is typically poor. Non-union rates are also high, as implants can interfere with adequate reduction and internal fixation. Megaprostheses are an option to facilitate early weight-bearing, but are fraught with complications including infection.

    In this article, we present a unique case of a periprosthetic proximal tibial fracture just distal to a well-fixed component and not enough bone stock to support a lateral locking plate.

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