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    What Is the Top Content Your Peers Are Accessing on ICJR.net?

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

    The Role of Dual Mobility Implants in Reducing Instability in Primary THA
    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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    FEATURED SURGERY: Robotic-Arm Assisted Total Knee Surgery
    Published June 24, 2019

    Watch Jeffrey T. Hodrick, MD, from the Southern Joint Replacement Institute, Nashville, Tennessee, perform a robotic-arm assisted total knee surgery on a 78-year-old male with progressively worsening right knee pain in a procedure broadcast live to attendees at ICJR’s inaugural Emerging Technologies in Joint Replacement meeting.

    The patient has experienced symptoms for several years and has failed conservative management, including non-steroidal anti-inflammatory drugs and 2 corticosteroid injections. The pain, located in his medal and lateral joint line, wakes him up at night and makes it difficult to go up and down the stairs.

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    The Disappearing Stem: The Changing Humeral Side of Shoulder Arthroplasty
    Published 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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    Stem Exchange in Revision TKA for Periprosthetic Fracture
    Published 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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    SURGICAL PEARLS: Revising a Failed UKA to TKA
    Published August 8, 2019

    Unicompartmental knee arthroplasty (UKA) is a great option for a subset of patients with osteoarthritis (OA) in a single compartment of the knee, as it is a reliable and durable operation when done well, said Rafael J. Sierra, MD, from Mayo Clinic, Rochester, Minnesota, at ICJR’s 7th Annual Revision Hip & Knee Course.

    What’s up for debate, he said, is the difficulty in revising a UKA to a TKA, the survivorship of the revision, and patient satisfaction after the revision procedure.

    A study just published in The Lancet found that that over a 5-year period, patients who undergo UKA have similar, if not a slightly better, clinical outcome compared with patients who undergo total knee arthroplasty (TKA), with substantial economic benefit.

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    Latissimus Dorsi and Teres Major Tear in a Throwing Athlete
    Published 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.

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    What Does the Future Hold for Prevention of PJIs?
    Published July 10, 2019

    Advances in technology and new thinking on prevention strategies will be the keys to reducing the risk of periprosthetic joint infections (PJIs) in total joint arthroplasty (TJA) patients.

    That’s the takeaway message from a presentation by Kevin I. Perry, MD, on PJI prevention and diagnosis in the future at ICJR’s inaugural Emerging Technologies in Joint Replacement course.

    Prevention begins in the preoperative period, and Dr. Perry said the biggest push will be in efforts to modify host risk factors.

    For example, obesity is associated with increased risk of nearly every complication of TJA, and it is known to be 1 of the single greatest contributors to PJI in patients with obesity. [1] What’s needed, Dr. Perry said, are strategies to manage these patients before and after surgery to reduce their risks. Bariatric surgery and long-term antibiotic use have been suggested, but Dr. Perry said a culture change may be more valuable.

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    Dispelling Myths and Legends about Total Joint Arthroplasty
    Published July 3, 2019

    Do orthopaedic surgeons practice evidence-based medicine?

    Sometimes yes, sometimes no, according to Bryan D. Springer, MD: Data suggest, he said, that evidence-based medicine and clinical practice guidelines are followed about 50% of the time.

    Consider the use of cementless stems in primary total hip arthroplasty. The literature overwhelming shows that older patients – especially older females – are at increased risk of periprosthetic fractures with cementless compared with cemented stems. Yet data from the American Joint Replacement Registry show that in the US in particular, these patients continue to receive cementless stems despite the known risk.

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    What Causes Hip Pain after Total Hip Arthroplasty?
    Published July 23, 2019

    Evaluating a patient who presents with a painful hip following total hip arthroplasty (THA) calls for a broad differential diagnosis and an understanding that THA failure is multifactorial and may require several visits, testing, and consultation with colleagues to arrive at the right diagnosis.

    And, said Tad M. Mabry, MD, at ICJR’s 7th Annual Revision Hip & Knee Course, the surgeon needs to keep in mind that not every patient with a painful THA needs another procedure: If the cause of the pain is unclear, reoperation is not likely to result in meaningful improvement in pain and function.

    During his presentation, Dr. Mabry reviewed the common and not-so-common intrinsic and extrinsic failure modes for THA

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    What Are Your Perioperative Protocols for Primary TKA Patients?
    September 4, 2019

    ICJR: Do you have a BMI cutoff for considering patients for primary total knee arthroplasty (TKA)? Is it a hard cutoff or a soft cutoff? If the patient’s BMI has decreased but is still above your cutoff, will you perform surgery?

    Denis Nam, MD, MSc: I would describe my BMI cutoff as “soft.” My target BMI is less than 40 kg/m2, but I explain to patients that this is really a continuous scale and that even a BMI of more than 35 kg/m2 can increase their risk of perioperative complications. Thus, the more weight they can lose, the better.

    I counsel patients with a BMI over 40 kg/m2 on the benefits of weight loss and ask them to speak to a nutritionist. Our medical center has a lifestyle program to which patients can be referred, and it includes a nutritionist and bariatric surgeon for evaluation and counseling. If a patient has made an earnest attempt to lose weight, I will often still proceed even if their BMI remains greater than 40 kg/m2, depending on the presence of other co-morbidities and risk factors.

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