What’s New in Hand Surgery: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the March 18, 2015 Specialty Update on hand surgery:

Distal Radial Fractures

–A study that randomized 50 patients with unstable radial fractures and Kirschner-wire fixation to receive demineralized bone-matrix allograft or no graft found no significant differences in bone density or function throughout one year of follow-up.

–Among 130 patients with a displaced distal radial fracture who were randomized for treatment with either a volar plate or percutaneous pins (with or without external fixation), plate-treated patients had a quicker return to function, but functional results were similar between the two groups at three months and one year.

Trapeziometacarpal Arthritis

–A randomized trial of 43 women aged 40 and older with trapeziometacarpal osteoarthritis comparing trapeziectomy with trapeziometacarpal arthrodesis (with plate and screws) was terminated early because of the high complication rate in the arthrodesis group.

Carpal Tunnel Release

–A Cochrane Database systematic review of 28 studies comparing endoscopic and open carpal tunnel release concluded that both techniques provided similar outcomes, but that the current literature on the subject is rife with low-quality studies.

–A meta-analysis of 21 studies comprising 1,859 patients that compared endoscopic and open carpal tunnel release showed that endoscopically treated patients had modestly greater strength at early follow-up but that the difference disappeared after six months.

This Specialty Update also includes many recent findings from papers presented at 2014 meetings of the American Society for Surgery of the Hand and the American Association for Hand Surgery.

Trunnion Failure Leads to Head-Neck Dissociation in Modular THA

HeadTrunnion Failure-neck modularity in total hip arthroplasty (THA) components confers several advantages, including intraoperative flexibility and precision that allow surgeons to adjust leg length and femoral offset. Also, in this age of “value-based purchasing,” modular hip implants may help hospitals reduce their implant inventory.

But modularity has its drawbacks, one of which is the increased number of interfaces at which wear and corrosion can occur. These metallurgical phenomena increase the risk of mechanical failure, metallosis, and adverse soft-tissue reactions.

In the April 22, 2015 edition of JBJS Case Connector, Arvinte et al. describe the case of a 64-year-old man who presented with a sudden onset of left groin pain and an inability to bear weight. Fourteen years earlier surgeons had performed a left THA using a modular titanium-alloy stem with a 6-degree trunnion taper and 32-mm cobalt-chromium head. The patient described intermittent but painless clunking in the same hip beginning five years after THA.

Radiographs showed a clear dissociation between the femoral head and neck. During revision, surgeons noted metallosis but no evidence of infection. Macroscopic examination of the removed components revealed substantial fretting and corrosion wear at the proximal part of the trunnion, leading the authors to conclude that chronic failure of the trunnion caused the eventual dissociation of the modular head. They speculated that the failure process may have begun with the clunking in the hip five years after the initial THA.

The patient made an unremarkable recovery and had excellent clinical and radiographic outcomes at the nine-year follow-up. The authors suggest that the onset of clicking or clunking in a modular hip “should be investigated as it may be a harbinger of head-neck dissociation.”

JBJS Editor’s Choice—Clavicle-Fracture Fixation and Golf-Club Selection

swiontkowski marc color

Golf enthusiasts endlessly debate club design and selection when approaching standard situations on the course. For example, for a shot to a large green from 100 yards, one golfer might choose a pitching wedge, while another would opt for a sand wedge or even a chocked-down nine iron. There are no style points in golf for this shot—what matters is getting the ball close to the pin.

There is a strong similarity between this club-selection dilemma and fixation of midshaft clavicle fractures. Two well-done Level I randomized controlled trials in the April 15, 2015 edition of The Journal (van der Meijden et al. and Andrade-Silva et al.) support the notion that, when a patient’s fracture displacement and clinical characteristics warrant fixation, it does not matter whether the surgeon chooses an intramedullary pin or a plate. This decision must be made based on the surgeon’s experience, skill, prior outcomes, and a candid discussion of the options with the patient.

One area of particular concern is the highly comminuted midshaft fracture that is not length-stable. The Andrade-Silva et al. trial showed that, in this setting, the reconstruction plate may well result in clavicular shortening that is statistically greater than shortening with the intramedullary device, but was not found to be clinically important. Still, in those cases a more rigid plate construct may be preferable.

Otherwise, pin or plate achieves equivalent clinical outcomes, just as the sand wedge and pitching wedge can both get the ball close to the pin. It is the experience and skill of the person with the club in hand that matters.

Click here for a commentary by Gordon Groh, MD on the Andrade-Silva et al. article.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

JBJS Classics: Open Fracture Infection Prevention

JBJS-Classics-logoEach month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

The common knowledge applied in managing open fractures (asepsis, irrigation and debridement, immobilization, and wound protection against infection) was obtained from the surgical experience accrued during World War I. Despite the overall improvement in outcomes from applying that knowledge, the varying severity of associated soft-tissue injuries created considerable ambiguity regarding optimal treatments during the years that followed.

”Prevention of Infection in the Treatment of 1,025 Open Fractures of Long Bones” by Ramon Gustilo and John Anderson in the June 1976 edition of JBJS classified open fractures into three types of increasing severity based on wound size, level of contamination, and osseous/soft-tissue injury.  In general, more severe open fractures have a worse clinical prognosis for infection, nonunion, and other complications, although actual outcomes vary depending on numerous additional clinical factors. Also, high-energy Type III open fractures are not homogeneous, and in response to that variation, in 1984 Gustilo et al. further classified Type III open fractures into A, B, and C subtypes according to the severity of soft-tissue injury, the need for vascular reconstruction, and worsening prognosis.

However, the reliability of the Gustilo classification has been questioned in recent years. Clinical researchers have observed that the assessment of surface injuries does not always reflect deeper damage and does not account for tissue viability and tissue necrosis, which tends to develop with time after high-energy injuries. Also, a 1993 study found only moderate interobserver agreement among users of the classification. The limitless variety of injury patterns, mechanisms, and severities is almost impossible to be contained in a limited number of discrete categories.

As the management of open fractures continues to evolve, the 1976 Gustilo and Anderson treatment recommendation against primary internal fracture fixation for most Type III injuries due to high infection rates no longer represents the standard of care. Stabilization, even with internal fixation, for many of these fractures promotes healing, allows early rehabilitation, restores function, and reduces the risk of infection and malunion.

While “best practices” may have changed, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains an easy-to-use classification system that has formed the foundation for open fracture management during the last four decades, with good but imperfect prognostic and therapeutic implications. It remains widely accepted for research and training purposes, and it provides the preferred basic language for communicating about open fractures.

Konstantinos Malizos, MD, PhD

JBJS Deputy Editor

ACL Self-Repair Moving Toward Reality

Attempts by orthopaedists to repair torn human ACLs have failed for the most part, so surgeons now rely almost exclusively on removing the torn ligament and replacing it with autograft or allograft tissue. But now research at Harvard by Martha Murray, MD—a co-author of several JBJS studies—suggests that a torn ACL can be prompted to repair itself.

As Dr. Murray explains in a video, “bridge-enhanced” ACL repair uses stitches and a spongy scaffold injected with the patient’s blood placed between the torn ends of the ACL. The bridge helps healing clots to form and helps surrounding cells grow to rejoin the ends of the ligament. Preclinical studies using this technique have resulted in successful ACL repairs and rates of subsequent knee arthritis that were lower than those seen with reconstruction techniques. Bridge-enhanced ACL repair would also eliminate the need for tissue harvesting in the many patients who choose the autograft reconstruction option.

After reviewing the data from the preclinical studies, the FDA approved the first safety study of this technique in humans, which is now underway.

SGR, RIP

On April 14, 2015 the Senate voted 92-to-8 to approve legislation previously passed by the House that puts an end to the SGR-based physician payment formula for Medicare services. At posting time, President Obama said he would sign the bill. The Senate-passed measure is identical to the bill approved by the House; all amendments introduced in the Senate were defeated.

After the vote, many medical societies, including the AMA and AAOS, heaped praise on Congress. In a rare moment of brevity from Capitol Hill, Michigan Rep. Fred Upton told Kaiser Health News (KHN), “Stick a fork in it. It’s finally done.”

But according to KHN, “while the law lays out a structure on how to move to new [Medicare] payment models, much of their development will be left to future administrations and federal regulators.” And an even colder rain on the parade came in a report from Paul Spitalnic, the head actuary at the Centers for Medicare and Medicaid Services (CMS). Spitalnic’s report soberly observes that the legislation about to be signed into law “raises important long-range concerns that would almost certainly need to be addressed by future legislation.” While the bill specifies physician payment-update amounts for all future years, the CMS report says that “the specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large.”

So while orthopaedists in the twilight of their active-practice careers may be able to “stick a fork in it,” younger surgeons may be distracted by debates about physician Medicare payments that are apt to crop up again.

Fracture Liaison Service Addresses Epidemic of Osteoporosis

The statistics about osteoporosis and associated fragility fractures are sobering:

  • One-quarter of adults living in the US currently have osteoporosis or low bone density.
  • Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
  • Patients who have had one fragility fracture have an 86% increased risk for a second fracture.

Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.

The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.

The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.

 

JBJS Reviews Editor’s Choice–Achilles Tendon Ruptures

Among the topics that consistently stimulate debate among orthopaedic surgeons is the treatment of acute Achilles tendon rupture. The central question is typically, “Should this injury be treated operatively or nonoperatively?” In the April 2015 issue of JBJS Reviews, Guss et al. tackle this question.

The decision to treat acute Achilles tendon rupture has always been a trade-off between wound complications (associated with operative treatment) and the risk of rerupture (associated with both nonoperative and operative treatment but more commonly associated with nonoperative treatment). While the authors quote numerous reports, an important observation among all of the reports cited is that rehabilitation protocols for nonoperative treatment were not uniform across cohorts. Considering recent findings, the debate about operative vs. nonoperative intervention apparently has shifted from a focus on rerupture and infection to a focus on functional outcomes. Functional rehabilitation protocols have decreased the rerupture rate historically seen in association with the nonoperative treatment of these injuries. Operative treatment may provide some functional benefits, but recent studies suggest that many of these benefits are transient or subtle.

Guss at al. also point out that the rate of deep-vein thrombosis after Achilles tendon rupture may be higher than that observed in association with many other foot and ankle conditions. Indeed, the incidence of deep-vein thrombosis in patients with acute Achilles tendon rupture is possibly as high as one in three, but the vast majority of deep-vein thromboses are asymptomatic and are unlikely to be clinically relevant. Prophylactic anticoagulation should be considered for older patients with Achilles tendon rupture, including those managed nonoperatively, as well as for patients with other known risk factors.

In summary, recent reports have suggested that the use of functional rehabilitation in lieu of cast immobilization has, to a certain extent, reduced the higher rates of rerupture that historically have been associated with nonoperative treatment. Moreover, functional rehabilitation protocols are not associated with the wound complications that are inherently associated with operative repair. Operative repair may provide functional benefits, but reports have suggested that these benefits may be transient or incremental and limited to those patients who participate in more intense athletic endeavors. Indeed, more research with well-designed, randomized clinical trials is necessary to clarify the potential for incremental functional gain following operative repair as well as to identify those patients in whom nonoperative treatment is more likely to fail.

Thomas A. Einhorn, MD, Editor

Click here for another OrthoBuzz post about this JBJS Reviews article.

Functional Rehab Key to Nonoperative Management for Achilles Ruptures

The fact that 12 of the 16 AAOS clinical practice guidelines for treating Achilles tendon ruptures are supported by “weak” or “inconclusive” evidence makes the recent JBJS Reviews article by Guss et al. on this subject all the more welcome.

The most emphatic point made by these authors is that functional rehabilitation protocols with early motion (and an associated shift away from long-term post-injury immobilization) have made a dent in the re-rupture rates historically seen with nonoperative treatment of Achilles tendon injuries, the incidence of which has increased in recent decades. The authors emphasize, however, that the delicate balance between loading and unloading of a healing Achilles tendon remains a rehabilitative challenge, and they encourage further research to identify which patients are more or less likely to experience success with nonoperative management.

The authors note also that the focus of outcomes research of different management methods has shifted from rates of re-rupture and infection to more specific functional measures—and, in some cases, to direct and indirect cost measures. For example, Guss et al. cite one meta-analysis that found that operatively treated patients returned to work almost three weeks earlier than those treated nonoperatively.

The authors also observe that the rate of deep vein thrombosis after Achilles rupture seems to be higher than that seen in other foot/ankle conditions, but they add that the majority of those thrombotic events are “unlikely to be clinically important.” Still, Guss et al. conclude that “prophylactic anticoagulation should be considered for older patients with an Achilles tendon rupture, including those treated nonsurgically.”

Treatments for Lumbar Spinal Stenosis Compared

Two interesting investigations into lumbar spinal stenosis (LSS) appeared in the general medical literature recently.

—A registry-based observational study of nearly 900 patients in the BMJ found that microdecompression techniques were as effective as open laminectomy in improving disability scores 12 months after surgery. The two techniques yielded similar quality-of-life scores at the one-year point, but the microdecompression patients had shorter hospital stays.

—In Annals of Internal Medicine, a multisite randomized study of 170 patients 50 or older with lumbar spinal stenosis found that those receiving surgical decompression and those receiving physical therapy (2 PT visits per week for six weeks focused on lumbar flexion and general conditioning) had essentially the same functional outcomes at time points ranging from 10 weeks to two years after enrollment. However, 57% of patients assigned to PT crossed over to surgery—some due to high copays for physical therapy, said study co-author Anthony Delitto, PT. In an editorial accompanying the study, JBJS Deputy Editor for Methodology and Biostatistics Jeffrey Katz, MD, concluded, “Because long-term outcomes are similar for both treatments yet short-term risks differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS.”

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