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Weekly News, Analysis, and Commentary

Orthopaedic Crossfire® Features & News

Gehrke, Cameron Debate Use of Cement in Small Canals

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Image created by RRY Publications, LLC

When it comes to small canals, with cemented stems you get better outcome and survival, fewer dislocations, fewer periprosthetic fractures, and fewer revisions!” argues Thorsten Gehrke. Hugh Cameron says, “Small stems are short and lucency will develop. And with cement in small canals you are reaming heavily and most of the cancellous bone is removed, thus the bone-cement interlock is poor.”

Lachiewicz, Jacobs Debate CCK in Intraoperative MCL Injury

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Image created by RRY Publications, LLC

“There is a great track record on constraint for intraoperative MCL injury. The bonuses: no need for sutures or staples, no need for a hinged knee brace, full weight bearing, early ROM, and excellent long term survival!” argues Paul Lachiewicz. But Josh Jacobs counters, “CCKs in primary TKR are not very conservative…you’re resecting a lot of bone. And there are issues of wear and ease of removal.”

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Dunbar, Haddad Debate Femoral Neck Modularity in Primary THA

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Image created by RRY Publications, LLC

“Femoral neck modularity lacks proof of superiority, increases the risk of corrosion and fracture, and makes everyone’s life miserable,” argues Mike Dunbar. “Let’s not overreact,” cautions Fares Haddad. “We need to learn from modular implant failures and then move forward and still be able to use modularity for patients in the future.”

Murphy, Rodriguez Debate Superior Capsulotomy

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Image created by RRY Publications, LLC

“With superior capsulotomy there is no fluoro or X-ray required, there is more accurate component placement, and it’s extensile,” argues Stephen Murphy. “And there is a 23% lower cost over 90 days.” Jose Rodriguez counters, “The major reason why this hasn’t spread is that you have to buy into navigation. Then there is technical ability; it’s a very different technique. It’s quirky, and you lose tactile feedback.”

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Perka Debates Barrack Over Ceramic on Ceramic Hip

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Image created by RRY Publications, LLC

“Ceramic-ceramic is a good option for the young, active patient. It is wear resistant, has improved lubrication, and allows thin inserts for large heads,” argues Carsten Perka. “Ceramic has long been on a steady decline,” says Robert Barrack. “There are malposition issues (leading to impingement and potential for failure), liner breakage and mal-seating and squeaking. Why pay more for something that is not improved?”

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Jones v. Mullaji: The Tourniquetless Total Knee

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Image created by RRY Publications, LLC

“Let it bleed,” argues Dickey Jones. “Tranexamic acid has been a game changer, and use of a CarboJet increases cement penetration. You don’t need a tourniquet.” Arun Mullaji says, “You should use a tourniquet because it helps reduce blood loss, provides much better clarity, and it gives you a better cement mantle.”

Lombardi Takes on Ranawat Over Bi-Cruciate Retaining Total Knees

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Image created by RRY Publications, LLC

“With bi-cruciate retaining knees the patient has normal kinematics, improved range of motion, and pain relief is equivalent to a total knee,” argues Adolph Lombardi. “We are repeating the mistakes of the past,” counters Chit Ranawat. “You must match the lateral condyle posterior slope—very hard. Preserving both cruciate ligaments is technically challenging. And the most quoted paper on this (by Cloutier) found that the survival rate at 20 years was no better than other knees done at the same time.”

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Padgett v. Dorr: Constrained Sockets in Revision Hips

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Image created by RRY Publications, LLC

“Constraint should be reserved for cases where there are no other options. These liners can compromise fixation and they don’t always work,” argues Doug Padgett. “Failure with constrained liners is caused by either poor judgment or poor technique,” counters Larry Dorr. “Dual mobility is hot stuff, but it’s going up against the tried and true constrained liner.”

Lachiewicz, Su Debate Dual Mobility in Primary Hip Replacement

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Image created by RRY Publications, LLC

“All the benefits to dual mobility are theoretical,” argues Paul Lachiewicz. “There’s little lab data—except from the manufacturers.” “Dual mobility has a proven track record,” counters Edwin Su. “It could be indicated for primary hip because it provides greater stability and it can reduce your dislocation rate to less than 1%. I would consider it in high risk, primary cases.”

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MacDonald, Haddad Debate Femoral Head Materials

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Image created by RRY Publications, LLC

Cobalt-chrome or delta (ceramic) heads? According to Steve MacDonald, cobalt-chrome wins because: “There’s no evidence of decreased revision rates with a delta head and it’s more expensive.” Counters Fares Haddad: “If you look at the level one data, you will move away from cobalt-chrome heads.” Excellent debate!

Whiteside, Rosenberg Debate Cementless, Cemented Revision

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Image created by RRY Publications, LLC

“With cemented TKA, if you have the right skill level, instruments, design, fixation, and the correct implant, then you can guarantee your patients a well fixed TKA,” says Leo Whiteside. Aaron Rosenberg isn’t so sure about that guarantee. “The registries show a significantly higher rate of revision amongst uncemented knees. Besides, the data is trending towards cementless TKA.”

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Parvizi v. Maloney Over Direct Anterior

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Image created by RRY Publications, LLC

“There isn’t a single randomized prospective study showing that the direct anterior is worse than other approaches,” says Jay Parvizi. “It’s the marketing,” says Bill Maloney. “This approach is being pushed by patients because of that. And it’s harder clinically…in part because you can’t easily visualize the femur.”

Paprosky, Callaghan Debate Constraint Versus Big Heads

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Image created by RRY Publications, LLC

“Cup position is critical,” says Wayne Paprosky. “And if the abductors are deficient then I’m not sure there is an advantage to constrained liners.” “Really?” says John Callaghan; “There are good results with large heads in revision surgery. And if you need something very large you can go to the dual mobility rather than jumping straight to a constrained liner.”

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Lee v. Lombardi Over Patient Specific Instrumentation

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Image created by RRY Publications, LLC

“The data does not support the use of patient specific instrumentation (PSI),” says Gwo-Chin Lee. “Claims of decreased operative time and improved alignment are unfounded.” Adolph Lombardi states, “The majority of studies DO show decreased processing and sterilization time, turnover time, etc. And hey, these things could soon be delivered to your OR by drone.”

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Jones v. MacDonald Over Tourniquetless TKA

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Image created by RRY Publications, LLC

“OK, so you have a bloodless field using a tourniquet in TKA,” says Dickey Jones. “But there are many downsides, such as nerve damage and a delay in the recovery of muscle function.” Hold on says Steve MacDonald, “There is no clinical evidence of nerve damage or delays in muscle function recovery when employing a tourniquet.”

Gustke Debates Callaghan: Ultracongruent Liners or Posterior Stabilization

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Image created by RRY Publications, LLC

“An ultracongruent liner provides the same function and similar results to a PS liner,” says Ken Gustke. And it avoids the risk of clicking, post wear, etc. John Callaghan disagrees, “It’s all about motion. After 90-110 degrees of motion you need rollback…and a post provides that. An ultracongruent liner couldn’t possibly do that.”

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Gehrke Debates Haidukewych: Mega Prostheses

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Image created by RRY Publications, LLC

“Mega prostheses can work in elderly patients and osteopenic patients with poor bone stock who need a quick procedure,” says Thorsten Gehrke. George Haidukewych isn’t quite so sanguine. “I do a mega prosthesis as a last resort, with a very distal fracture, with severe osteolysis, etc.” and “ORIF remains the gold standard for periprosthetic fractures.”

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Su v. Lombardi: Yay or Nay to Metal-on-Metal Surface Replacement?

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Image created by RRY Publications, LLC

“Surface replacement trumps THR because it preserves bone, offers greater stability, and allows a higher activity level,” advocates Ed Su. “Keep in mind,” says Adolph Lombardi, “resurfacing is a more difficult operation with a high learning curve. Few patients meet the criteria…and there is concern over metal ion toxicity.”

Lee Debates Barrack: Ceramic-Ceramic THA

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Image created by RRY Publications, LLC

“Ceramic-ceramic hips have a place in young, active patients,” advocates Gwo-Chin Lee. “And they have the lowest wear rate.” Robert Barrack counters, “The new ceramics are better, but standard metal-crosslinked poly has improved more. And the 10-15 year results cannot be improved upon. Ceramic-ceramic isn’t ready for prime time.”

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Hofmann, Callaghan Debate the Posterior Stabilized Knee

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Image created by RRY Publications, LLC

“I haven’t saved a cruciate ligament in the last five years. It’s more difficult and less predictable. It’s more forgiving to take the PCL,” argues Aaron Hofmann. “A recent study found that ROM was better with the posterior stabilization,” counters John Callaghan. “And Chit Ranawat has had a 95% satisfaction rate with a PS knee…no revisions at 10 years.”

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Dunbar, Cameron Debate Modular Necks

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Image created by RRY Publications, LLC

“No modular necks for routine primary hip arthroplasty!” argues Michael Dunbar. “We have no proof of superiority and there is an increased risk of fracture and fretting, ion debris, etc.” Hugh Cameron counters, “Look, I’ve done more than 350 cases with no incidents of delayed metal hypersensitivity and no pseudotumors.”

Dunbar, Berend Debate the All Poly Tibia

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Image created by RRY Publications, LLC

“It’s undeniable that the all poly tibia is cheaper,” argues Mike Dunbar. “And there is no backside wear, more poly for the same tibial resection, better RSA data, and better survivorship.” “I agree that all poly components are equal to well-designed monoblock designs,” counters Mike Berend. “But caution…it’s design and technique sensitive.”

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McFarland, Gobezie Debate Treatment for Infected TSA

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Image created by RRY Publications, LLC

“This patient MAY be infected,” says Ed McFarland. “For patients who are even a bit ill, I would do a one-stage revision; those who are young and healthy get a two-stage revision. I don’t think debridement adds much.” Reuben Gobezie counters, “If you’re going to do anything to this patient, I think it would be reasonable to get an arthroscopic debridement at the most before you rip their arm out, Ed.”

Backstein v. Haidukewych Over the Mega Prosthesis

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Image created by RRY Publications, LLC

David Backstein has his favorite mega prosthesis system and he’s not giving it up any time soon. “You have shorter length of stay, and there is no chance of malunion or non-union.” George Haidukewych pulls the reins in, saying, “Mega prostheses have a limited role, namely, in situations where fixation is likely to fail. ORIF remains the gold standard for periprosthetic fractures.”

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Abdel v. Mullaji Over the Cementless Knee

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Image created by RRY Publications, LLC

Matt Abdel is all over cementless TKA. “It involves shorter operative times, preserves bone stock, means easier revision surgery, eliminates third body wear, etc.” Slow down, says Arun Mullaji. “With cementless TKA you’re paying more for a procedure for which the jury is still out. We don’t have good long term data and we don’t know what the optimum design is.”

Parvizi, Sculco Debate Simultaneous Bilateral TKA

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Image created by RRY Publications, LLC

A bilateral TKA procedure triggers higher rates of post-operative complications, says Javad Parvizi, M.D., F.R.C.S. and specifically cites rates of cardiac complications and pulmonary embolus. Actually, these procedures are safe, says Thomas Sculco, M.D. particularly as “We move towards improved patient selection, better anesthetic techniques, better perioperative care, and faster surgery.” Who wins this debate? Read on.

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