Tibial Loosening, Stem Fixation, and More: The Top Content Accessed on ICJR.net

    Which articles published on ICJR’s website were most accessed by orthopaedic surgeons and other orthopaedic healthcare professionals during the fourth quarter of 2019? Find out below.

    Tips for Preventing Tibial Loosening in Total Knee Arthroplasty
    Published on November 4, 2019

    Aseptic tibial loosening is the number 1 cause of failure leading to revision after total knee arthroplasty (TKA).

    That shouldn’t be the case: At the 7th Annual ICJR South Hip & Knee Course, Daniel J. Berry, MD, from Mayo Clinic in Rochester, Minnesota, said that surgeons know more now about how to cement knee implants than they did even 15 years ago and have – theoretically – gotten better at it.

    But the data suggest, he said, that surgeons have actually become worse at cementing knee implants. They’re rushing through the procedure, he said, using the wrong type of cement and the wrong cementing technique.

    So, there’s a lot of room for improvement, and surgeons can do better by focusing on:

    • Good alignment
    • Good cementing technique
    • Appropriate cement choice
    • Implant choice
    • Identification and management of high-risk patients


    Why Leg Length Discrepancy after THA Matters – and How It Can Be Prevented
    Published on 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.


    6 Reasons Why Cemented Stems Still Make Sense in Total Hip Arthroplasty
    Published on October 14, 2019

    There’s no reason to abandon cemented femoral components in primary total hip arthroplasty (THA), but there are plenty of reasons – well, at least 6 really good reasons – why cement is still relevant.

    Speaking at Essential Hip Topics: Cradle to Grave, ICJR’s 1-day pre-course for the Mid-American Orthopaedic Association’s annual meeting, Robert T. Trousdale, MD, said that registry data from the American Joint Replacement Registry show a decline in the use of cemented hip designs, while the use of cementless implants has been gradually increasing.

    He also noted that 47% of attendees at a meeting of the American Association of Hip & Knee Surgeons (AAHKS) had never done a cemented THA, while another 47% said they use cemented stems in fewer than 25% of their patients.

    Dr. Trousdale, from Mayo Clinic in Rochester, Minnesota, said the American registry data and the feedback from AAHKS meeting attendees strongly contrast with European data: The UK joint registry, for example, shows that cemented stems are used in about 50% of THAs, while in Sweden, the number is about 70%.

    But the number of cemented stems used in the US is not zero, Dr. Trousdale said, nor should it be.


    Patients to Avoid Until You’ve Done 100 Direct Anterior Approach THAs
    Published October 1, 2019

    Over the past decade, orthopaedic surgeons have become more and more interested in the direct anterior approach for total hip arthroplasty (THA) due to the reported benefits of shorter length of stay, greater likelihood of discharge home, and faster functional recovery, as well as 30-day major and minor complications similar to those of THA through the lateral and posterior approaches.

    Proficiency in the direct anterior approach takes time due to the nuances of acetabular and femoral exposure and component positioning, the different implants and instruments, and the need to train the OR staff. That’s why experts in the direct anterior approach generally recommend starting with “easier” patients and working up to more challenging cases as the surgeon and the OR team become more comfortable with the approach.

    So, who are the so-called “easier” patients? At ICJR’s 7th Annual Direct Anterior Approach Hip Course, Martin Thaler, MD, MSc, from the Medical University Innsbruck in Austria, recommended starting with these patients:

    • Average weight or thin
    • Average muscle mass or lean
    • Decent bone quality
    • Active
    • Osteoarthritis
    • Older but not too old


    CMS Is Removing THA from the Inpatient-Only List
    Published on November 21, 2019

    The Centers for Medicare and Medicaid Services (CMS) has published its final rule on the Medicare Hospital Outpatient Prospective Payment System (CMS-1717-FC) and the Ambulatory Surgical Center Payment System for calendar year 2020, and as orthopaedic surgeons have been expecting, total hip arthroplasty was removed from the Inpatient-Only List.

    In addition, total knee arthroplasty has been added to the Ambulatory Surgery Center Covered Procedures List.

    The comment period for this final rule ended on Monday, December 2, and the rule is scheduled to take effect on January 1, 2020.

    CMS says that the changes in the rule, “build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System.”

    In a September 27 letter to Seema Verma, MPH, Administrator for CMS, the American Academy of Orthopaedic Surgeons (AAOS) had strongly objected to CMS removing THA from the Inpatient-Only List, citing the confusion that followed removal from TKA from the list in 2018.


    The Disappearing Stem: The Changing Humeral Side of Shoulder Arthroplasty
    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.


    The origin of TSA dates back to Themistocles Gluck, a German surgeon who developed ivory endoprostheses in the 1880s, and Jules-Emile Péan, a French surgeon credited with the first successful shoulder arthroplasty in 1893. [3].

    The operation did not begin to gain popularity until 1955 when Charles Neer published a case series on 12 patients who had undergone shoulder arthroplasty to treat proximal humerus fractures. The initial implant design he used was a monoblock stemmed prosthesis without glenoid resurfacing.

    Nearly 20 years later, Neer published on the use of proximal humeral arthroplasty to treat glenohumeral osteoarthritis, reporting promising results: More than 90% of patients experienced “satisfactory” or “excellent” outcomes. In 1977, Marmor described superior migration of the humeral head in patients deficient of a rotator cuff, establishing the cuff as a critical component of successful arthroplasty. [5]


    ICJR CASES: How Would You Manage These 10 Challenging TKA Patients?
    Published on October 30, 2019

    A 55-year-old male patient presents with bilateral degenerative joint disease. He’s otherwise healthy, with a BMI of 25 and no medical comorbidities. Do you offer simultaneous bilateral total knee arthroplasty (TKA), or do you recommend staged procedures?

    A 35-year-old, wheelchair-dependent female patient presents with right knee pain. She’s undergone 3 knee arthroscopies and is now on oxycodone, 80 mg twice a day, for the pain. How will her opioid use factor into your surgical plan?

    A 68-year-old male patient with right knee pain has hardware in that leg from a distal femur fracture 30 years prior. He has failed conservative therapy and wants a TKA to relieve the pain that is substantially limiting his activities. How will you deal with the existing hardware?

    These complicated primary TKAs were among the cases moderator Matthew S. Austin, MD, presented to a panel of experienced surgeons at ICJR’s 11th Annual Winter Hip & Knee Course, asking them to review the physical exam and radiographic findings and then – on the spot – to comment on how they would manage the patients.


    ICJR DEBATES: Cemented vs. Cementless Stem Fixation in Revision TKA
    Published on December 5, 2019

    What is the optimum method of stem fixation in a revision total knee arthroplasty (TKA) procedure? Is cemented fixation necessary, or is a cementless technique adequate?

    As it turns out, either one is acceptable: The literature does not unequivocally favor one over the other, with both fixation methods having been found to be effective. [1]

    The choice of fixation technique come down to surgeon preference and quality of the patient’s bone. Cemented and cementless fixation (or a hybrid cemented/cementless fixation) have their advantages and disadvantages. [2] In general, surgeons tend to select cemented fixation in patients with large bone defects and/or poor bone quality to ensure metaphyseal engagement, while cementless or hybrid fixation is appropriate for most routine revision procedures. [2]

    At ICJR’s inaugural course for senior residents and fellows, Advanced Techniques in Total Hip & Knee Arthroplasty, Matthew P. Abdel, MD, and H. John Cooper, MD, addressed the question of cemented versus cementless fixation. Dr. Abdel described the 5 reasons he prefers to cement the stem in revision TKA, including the ability to achieve immediate fixation, while Dr. Cooper elaborated on the hybrid technique he uses in most revision scenarios to add strength and stability to the fixation and prevent aseptic loosening.


    Augmented Reverse Shoulder Arthroplasty for Complex Instability with Glenoid Fracture
    Published on November 13, 2019


    Reverse total shoulder arthroplasty (RTSA) has continued to increase in prevalence in the United States since its approval by the US Food and Drug Administration in 2004. Although the original indication of the implant design was to combat the anterior superior escape and pseudoparalysis patients experienced with rotator cuff arthropathy, its indications have expanded. RTSA is now used for many salvage and complex problems of the shoulder including:

    • Proximal humerus fractures
    • Revision arthroplasty surgery
    • Chronic or complex instability
    • Some instances of primary osteoarthritis

    The case reported in this article describes a patient with a traumatic shoulder dislocation and glenoid fracture who underwent RTSA with a metal augment to fill the defect created by the glenoid fracture.

    Case Presentation

    A 67-year-old, right-hand dominant female patient presents with a 3-week history of right shoulder pain. She had a trip and fall injury while at home, landing on her right side. She did not lose consciousness.

    At the emergency department, shoulder dislocation was diagnosed and reduced. The patient followed up with a non-operative physician, but after her first visit, she experienced increasing pain in the right shoulder.

    Repeat radiographs demonstrated recurrent dislocation with a bony abnormality noted on her glenoid. She was referred to an orthopaedic shoulder surgeon for further evaluation.


    Does the Surgical Approach Affect the PJI Rate in Total Hip Arthroplasty?
    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).

    In addition, the study sought to identify individual risk factors for PJI and to evaluate the impact of an infection prevention protocol adopted during the study period.

    The patient-specific and surgical risk factors examined included:

    • Age over 65 years
    • Gender
    • BMI over 35
    • Diabetes mellitus
    • Smoking
    • Alcohol use
    • Operative time over 120 minutes
    • High-volume surgeon (more than 100 cases per year)
    • Same-day discharge