What Your Peers Are Reading 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 second quarter of 2019? Find out below.
Extended Antibiotic Prophylaxis Can Reduce PJIs in Revision TKA Patients
Published June 6, 2019
In a study published at the end of last year, R. Michael Meneghini, MD, and his colleagues from the Indiana University School of Medicine reported that high-risk primary total knee arthroplasty (TKA) patients who took antibiotics for 7 days after surgery were nearly 5 times less likely to develop a periprosthetic joint infection (PJI) than patients who did not take antibiotics postoperatively.
They concluded that this protocol of extended antibiotic prophylaxis resulted in a “statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection.”
They also wondered: Would the same be true of revision TKA patients?
ICJR REWIND: Techniques for Optimizing Acetabular Component Positioning in THA
Published April 9, 2019
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:
- Shell-liner dissociation
- Leg-length discrepancy
- Limited range of motion (ROM)
- Hardware squeaking in ceramic bearing hips
ICJR REWIND: An Update on DVT Prophylaxis for Total Joint Arthroplasty Patients
Published March 26, 2019
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.
FEATURED SURGERY: Cementless Total Knee Arthroplasty
Published April 18, 2019
In a pre-recorded surgery shown to attendees at the Winter Hip & Knee Course, R. Michael Meneghini, MD, from IU Health Saxony Hospital in Fishers, Indiana, performs a cementless total knee arthroplasty in an active, 58-year-old female patient. Between 20% and 30% of Dr. Meneghini’s patients are candidates for cementless TKA, which he said registry data and the literature support as a viable option for younger patients with good bone quality who need a long-lasting implant.
Dr. Meneghini was joined on the podium at the Winter Hip & Knee Course by a panel of surgeons who discussed the surgery and shared their experiences with cementless TKA. The panel included:
- James A. Browne, MD, as moderator
- Gregory G. Polkowski II, MD
- Scott M. Sporer, MD, MS
- Michael J. Taunton, MD
- Timothy J. Williams, MD
Is There an Optimal Dosing Regimen for TXA in Revision Total Knee Arthroplasty?
Published April 25, 2019
Tranexamic acid (TXA) is commonly used in topical, oral, and intravenous (IV) forms to safely and effectively reduce blood loss and transfusions in patients undergoing primary total knee arthroplasty (TKA). Less is known about the blood-sparing effects of TXA in revision TKA patients, who typically experience more blood loss than primary TKA patients.
To better understand the use of TXA in revision TKA, surgeons from 6 institutions in the US – Mayo Clinic, NYU Langone Health, Hospital for Special Surgery, University of California San Francisco, and Rush University Medical Center – participated in a randomized trial designed to evaluate 4 dosing regimens in patients undergoing septic and aseptic revision TKA:
- 1 gram of IV TXA before the first incision
- 1 gram of IV TXA before the first incision and 1 gram of IV TXA at wound closure
- 1 gram of IV TXA before the first incision and 1 gram of topical TXA intraoperatively
- 3 1950-mg doses of oral TXA: 2 hours preoperatively, 6 hours postoperatively, and the morning of POD1
Does Tramadol Have a Role in Managing the Pain of Knee OA?
Published May 16, 2019
Orthopaedic surgeons should use caution in prescribing tramadol to patients with knee osteoarthritis (OA): A study from NYU Langone Health has shown that total knee arthroplasty (TKA) patients who took tramadol preoperatively to treat knee OA had significantly less short-term improvement in functional outcomes than patients who were opioid-naïve.
Their findings were presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons.
The researchers retrospectively reviewed prospectively collected data on 199 patients (120 females, 79 males) who underwent primary TKA at their institution between January 2017 and March 2018. They grouped patients into 3 categories:
- Opioid-naïve patients (n=136)
- Patients who took tramadol (n=21)
- Patients who took other opioids (n=42)
FEATURED SURGERY: Anterior Approach THA
Published May 30, 2019
In a pre-recorded surgery shown to attendees at ICJR’s Winter Hip & Knee Course, Joel M. Matta, MD, from The Steadman Clinic in Vail, Colorado, performs an anterior approach total hip arthroplasty in a 67-year-old male patient with degenerative osteoarthritis of the left hip.
The patient has significant shortening of the left leg – nearly 1 cm shorter than the right leg – due to wear of the femoral head and acetabulum. Dr. Matta comments that he will review the radiographs of the contralateral hip intraoperatively to ensure that he is restoring the patient’s biomechanics, leg length, and offset.
Dr. Matta was joined on the podium at the Winter Hip & Knee Course by a panel of surgeons who discussed the procedure and answered questions from attendees:
- William P. Barrett, MD
- Daniel J. Berry, MD
- Michael J. Taunton, MD
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.
Tips and Techniques for Primary Total Knee Arthroplasty
Published April 8, 2019
At ICJR’s Winter Hip & Knee Course, Richard A. Berger, MD, from Rush University Medical Center in Chicago, Illinois, shared the tried-and-true techniques he relies on for surgical management of primary total knee arthroplasty (TKA) patients.
Restore bone loss and the joint line.
Most TKA patients have bone loss and flexion contracture, 2 issues that need to be addressed separately. However, surgeons have traditionally been taught to remove more bone from the distal femur, which Dr. Berger said doesn’t make sense because it leads to mid-flexion instability.
Do a bigger posterior release.
With that first point in mind, Dr. Berger removes less bone than he is replacing, which lowers the joint line. Because this worsens the flexion contracture, he compensates by doing a bigger posterior release, all the way on the lateral and medial sides. He may even take the entire posterior capsule off the back of the knee. He said this provides great range of motion, as well as stability throughout the arc of motion.
FEATURED SURGERY: Revision Total Knee Arthroplasty for Infection
Published May 9, 2019
In a pre-recorded surgery shown to attendees at the Winter Hip & Knee Course, Arlen D. Hanssen, MD, from Mayo Clinic, Rochester, Minnesota, performs a revision total knee arthroplasty (TKA) on a 70-year-old male patient with an infected knee.
The patient’s primary TKA had been done at a different institution. When he presented to Dr. Hanssen’s clinic, he had highly elevated inflammatory markers: erythrocyte sedimentation rate of 35 and C-reactive protein level of 57.
Three months prior to the reimplantation procedure shown in the video, the patient received an articulating antibiotic spacer. Cultures grew Staphyloccocus capitis and he was placed on intravenous cefazolin for 6 weeks.