Each 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 JBJS Classic Treatment of Scoliosis: Correction and Internal Fixation by Spinal Instrumentation by Paul R. Harrington describes 15 years of investigation, beginning in 1947, soon after Dr. Harrington completed his residency in Kansas City and headed an Army orthopaedic unit during World War II. The importance of this paper can’t be overstated. With this description of instrumentation that improved deformity outcomes, Harrington ushered in modern spine surgery. It was also one of the rare early examples of orthopaedic clinical science funded by a national grant.
The need for this daring, revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Polio patients comprised 75% of the first series described in this paper.
This comprehensive study combines theory, basic science, surgical techniques, and outcomes. With it, Harrington started the still-continuing dialogue about indications for scoliosis surgery with the comment that “clinical indications for therapy are still being worked out.” As a partial answer to the indications quandary, he introduced the Harrington factor—the number of degrees of primary curve divided by the number of vertebrae in the primary curve. This calculation continues to be used (renamed) in some current research into risks of curve correction, while debate continues about other indications such as progression, pain, and pulmonary issues.
The technique of spinal instrumentation is extensively described in this landmark article. Noteworthy is Harrington’s gradual embrace of the need for fusion and well-molded body cast immobilization, both of which he credits with improved results. (Initially Harrington had hoped to avoid fusion in many cases.) Although “instrumentation” today is nearly synonymous with “fusion,” some of our most promising ideas in deformity correction now involve instrumentation without fusion.
Also impressive is the respect with which Harrington treated the spinal cord and dura. He describes careful insertion of the hooks and recommends against downward hooks above L2, where the conus ends. This paper reminds us that we should always pursue the lowest-risk approach to instrumentation that will serve our patients. Dr. Harrington was also cognizant of the importance of blood loss, and meticulously measured it by stage of surgery. He showed that most blood loss occurred during subperiosteal dissection, a fact that we still recognize today.
Harrington’s description of selective thoracic fusion was illustrated radiographically in Figure 7, which shows a dramatic result where a 55° unfused lumbar curve declined to 18° after correction of a larger thoracic curve. This concept was further developed by Moe, King, Lenke and others, but the idea of spontaneous correction of lumbar curves started with the power of Harrington’s instrumentation.
The benefits of our more “modern” instrumentation are evident when reading the recommended aftercare in Harrington’s paper: a 16-day hospital stay, 8 weeks of bed rest, and a Risser localizer cast for 3 to 5 months, only to find out whether the patient might need reoperation for instrumentation problems or pseudarthrosis.
A modern journal editor might have expended some red ink on Dr. Harrington’s paper. The organization was less formal than many scientific papers today, but this may reflect the multiple simultaneous investigations and changes that took place during this decade-plus of revolutionary work. Dr. Harrington emphasizes that the results improved with each iteration of the procedure and device, which underwent more than three dozen design modifications.
Details on the curve sizes were not given, but we now recognize that curve size does not correlate linearly with clinical parameters. While Harrington does not describe the contributions of others who may have been involved in this work, neither does he use the eponymous term (“Harrington instrumentation”) that others attached to his spinal fixation device. While remarkable in its prescience, this paper did not anticipate the problems of distraction instrumentation in the lumbar spine, later characterized as Flatback Syndrome. It also did not elaborate on the need for differing mechanics in kyphoscoliosis or Scheuermann kyphosis.
Nevertheless, in this single article, Dr. Harrington laid the groundwork for three major themes that orthopaedists have further developed:
- The safety and benefits of metal fixation in spine surgery
- The use of growth guidance in patients < 10 years old
- The idea of selective thoracic fusion for double curves
Each of these ideas has generated hundreds of additional studies and papers to get us to modern practice. Just as current hip arthroplasty techniques represent incremental improvements on the monumental contribution of Charnley, current techniques in scoliosis surgery, especially of the thoracic spine, are but stepwise improvements on Harrington’s classic work.
Paul Sponseller, MD, JBJS Deputy Editor for Pediatrics
Marc Asher, MD, Professor Emeritus, Department of Orthopaedic Surgery, University of Kansas Medical Center
Among a prospectively enrolled group of 49 patients (54 wrists) with mild or moderate carpal tunnel syndrome (CTS) who received a single corticosteroid injection, 79% experienced symptom relief at six weeks. Reporting in the October 7, 2015 edition of The Journal of Bone & Joint Surgery, Blazar et al. found that the rate of freedom from symptom recurrence in this cohort was 53% at six months and 31% at one year after injection. During the study period, 19 wrists underwent surgical carpal tunnel release at a median time of 181 days post-injection.
Diabetic patients in the study (13% of the wrists enrolled) were at a 2.6-fold greater risk of reporting recurring symptoms within one year of follow-up. In a univariable analysis, a 1-point increase in the baseline Boston Carpal Tunnel Questionnaire symptom score increased the risk of patients reporting post-injection symptoms by 5%, but that association became nonsignificant during multivariable analysis. Pre-injection symptom duration, patient age, and pre-injection electrophysiologic grade did not predict either symptom recurrence or subsequent intervention.
Blazar et al. add that their exclusion of people with normal electromyography results and those with severe carpal tunnel syndrome created a rather homogenous study population. Thus, they say, “these results may not be generalizable to all patients who present with clinical signs or symptoms of carpal tunnel syndrome.” Still, the findings should help orthopaedists counsel patients with CTS about the results they might expect from a single corticosteroid injection.
Orthopaedic surgical procedures to correct axial and appendicular skeletal deformities are usually dependent upon fixation devices, either external or internal or both. These devices are often developed through close collaboration with engineers who are generally employed by major manufacturing companies. After the devices successfully clear rigorous bench, in-vitro, and in-vivo testing, the standard initial presentation of clinical results is a case series.
All too often the initial report of results comes from a co-developer of the device, with inherent selection and detection bias that constitute what most readers would consider a conflict of interest. McCarthy and McCullough’s case series on five-year results with Shilla growth guidance in 33 children with early-onset scoliosis in the October 7, 2015 JBJS is an exception to that rule. The authors report every conceivable major and minor adverse event without holding back any negative information. They categorize complications as infection secondary to wound breakdown, spinal alignment issues, and implant issues. The overall complication rate was 73%, a rate that is not surprising given the fact that the device under study is designed to maintain correction of spinal deformity in growing children.
Thankfully, the authors reported no neurologic complications. Also on the positive side, they found that spinal curves averaging 69° preoperatively averaged 38.4° at the most recent follow-up or prior to definitive spinal instrumentation. McCarthy and McCullough also calculated a 73% reduction in the number of surgical procedures among their cohort, relative to what would be necessary to treat the same population with distraction methods every six months.
I applaud the authors for comprehensively reporting the results of correction of spinal deformity in this difficult clinical situation with high accuracy and strict definitions of major and minor events. This is how we will make advances in correcting deformity for skeletally mature and immature patients—with innovation, incremental improvement, and the widespread sharing of adverse events with the orthopaedic community. Armed with the information from this study, we must now see what the number and severity of complications look like when the broader community of orthopaedic surgeons applies these devices.
Marc Swiontkowski, MD
In two separate studies published recently in the BMJ, New Zealand researchers concluded that increased calcium intake, through diet or supplements, is unlikely to have clinically meaningful effects on bone density or fracture prevention. The findings call into question recommendations from most health care professionals for daily calcium intake of at least 1,000 to 1,200 mg in older adults.
The first study reviewed 59 randomized controlled trials (nearly 14,000 patients total) that examined the association between bone mineral density (BMD) and either dietary or supplemental sources of calcium. Increases in BMD ranged from only 0.6% to 1.8% with increased calcium intake, regardless of the source and whether calcium was taken with vitamin D. The authors concluded that these small BMD effects were “unlikely to translate into clinically meaningful reductions in fractures.”
The second study reviewed 28 randomized trials and 44 observational studies (more than 58.000 patients total) that examined the relationship between increased calcium intake and fracture prevention among people older than 50 years. The analysis found that calcium supplements have “small inconsistent benefits on fracture prevention” but that overall “there is currently no evidence that increasing calcium intake prevents fractures.”
What do you make of these findings? Please comment by clicking on the “Leave a comment” button in the box next to the title.
There are currently no standards or regulations governing when it’s safe to drive after a knee replacement. But researchers reporting in the American Journal of Physical Medicine & Rehabilitation found that patients with right-knee replacements using an automatic-transmission driving simulator had 30% slower braking times eight days after surgery compared with presurgery measurements.
Braking times were significantly reduced in the right-knee group for six weeks and reached preoperative levels at 12 weeks postsurgery. Braking time was only 2% slower after left-knee replacements, but braking force, a crucial factor in emergency stopping, decreased by 25% to 35% in both groups during the week after surgery.
The authors conclude that, while “categorical statements cannot be provided,” these automatic-transmission findings suggest that “right TKA patients may resume driving six weeks postoperatively.” However, even the presurgery measures of braking time and force that these researchers used may not represent “normal” values because severe osteoarthritis can impair driving skills. And the findings have no bearing on TKA patients who drive manual-transmission cars with clutch pedals.
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 August 19, 2015 Specialty Update on limb lengthening and deformity correction:
Pediatric Disorders and Trauma
–A modified guided-growth technique for insertion of tension-band plates decreased operative time, radiation exposure, and incision size.1
–Two meta-analyses concluded that, although oral or intravenous bisphosphonates in children with osteogenesis imperfecta increased bone mineral density, evidence of reduction in fracture rates was inconclusive.2, 3
–A systematic review of 40 studies on surgical management of posttraumatic cubitus varus in children noted an overall complication rate of 14.5%, with no single technique being substantially safer or more effective.4
Lower-Limb Trauma/Reconstruction in Adults
–A prospective randomized study on the surgical treatment of complex knee dislocations with ligament reconstruction found a significantly lower risk of delayed ligament failure with adjunctive hinged external fixation compared with a hinged knee brace.
–A prospective randomized study comparing biplanar external fixation with reamed interlocking intramedullary nailing for treating open tibial shaft fractures found similar healing rates and functional outcomes one year postoperatively.5
–Patients with extra-articular distal tibial fractures treated with circular external fixators had earlier weight-bearing and superior function compared with those managed with plate fixation.6
–A randomized controlled trial of patients with medial compartment knee osteoarthritis reported similar radiographic outcomes six years postoperatively among those who had opening-wedge high tibial osteotomy compared with those who had undergone closing-wedge high tibial osteotomy. The closing-wedge group had fewer complications but greater prevalence of conversion to total knee arthroplasty.
Foot and Ankle Reconstruction
–A multicenter prospective study comparing ankle arthroplasty with ankle arthrodesis noted similar patient-reported outcomes, although revision rates and major complications were higher following ankle replacement.
Managing Postoperative Complications
–A comparative study noted a lower prevalence of pin-site infections with the use of chlorhexidine (9.2%) compared with povidone-iodine (27.9%) following external fixation.7
–A randomized study revealed a 27% reduction in external fixation time with the use of low-intensity pulsed ultrasound for tibial osteoplasty.8
–A randomized trial in patients undergoing bilateral tibial lengthening showed no improvement in postoperative pain or ankle-joint mobility following botulinum toxin A injection in the calf muscle.9
New Tools and Techniques
–In a matched-pair study, patients undergoing femoral lengthening using a motorized intramedullary nail showed better consolidation indices, better knee mobility, and decreased complication rates compared with conventional external fixation.10
- MasquijoJJ, Lanfranchi L, Torres-Gomez A, Allende V. Guided growth with the tension band plate construct: a prospective comparison of 2 methods of implant placement. J Pediatr Orthop. 2015 Apr-May;35(3):e20
- Dwan K, Phillipi CA, Steiner RD, Basel D. Bisphosphonate therapy for osteogenesis imperfecta. Cochrane Database Syst Rev. 2014;7:CD005088. Epub 2014 Jul 23
- Hald JD, Evangelou E, Langdahl BL, Ralston SH. Bisphosphonates for the prevention of fractures in osteogenesis imperfecta: meta-analysis of placebo-controlled trials. J Bone Miner Res.2014 Nov 18
- Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Joint J. 2014May;96-B(5):691-700
- Rodrigues FL, de Abreu LC, Valenti VE, Valente AL, da Costa Pereira Cestari R,Pohl PH, Rodrigues LM. Bone tissue repair in patients with open diaphyseal tibial fracture treated with biplanar external fixation or reamed locked intramedullary nailing. Injury. 2014 Nov;45(Suppl 5):S32-5
- Fadel M, Ahmed MA, Al-Dars AM, Maabed MA, Shawki H. Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia. Int Orthop. 2015 Mar;39(3):513-9. Epub 2014 Dec 5
- Cam R, Demir Korkmaz F, Oner Şavk S. Effects of two different solutions used in pin site care on the development of infection. Acta Orthop Traumatol Turc.2014;48(1):80-5
- Salem KH, Schmelz A. Low-intensity pulsed ultrasound shortens the treatment time in tibial distraction osteogenesis. Int Orthop. 2014 Jul;38(7):1477-82. Epub 2014 Jan 7
- Lee DH, Ryu KJ, Shin DE, Kim HW. Botulinum toxin A does not decrease calf pain or improve ROM during limb lengthening: a randomized trial. Clin Orthop Relat Res.2014 Dec;472(12):3835-41
- Horn J, Grimsrud Ø, Dagsgard AH, Huhnstock S, Steen H. Femoral lengthening with a motorized intramedullary nail. Acta Orthop. 2015 Apr;86(2):248-56. Epub 2014 Sep 5
Infections of the spine are particularly challenging to orthopaedists because they often present emergently, can be difficult to diagnose precisely, and can have catastrophic or fatal outcomes if not treated effectively.The September 23, 2015 “Case Connections” from JBJS Case Connector discusses five cases of rare but serious spinal infections.
The “Case Connections” springboards from a September 9, 2015 JBJS Case Connector case report by Rosinsky et al. that describes a sixty-five-year-old man who presented with fever and intractable lumbar pain that radiated to his right leg. In this case, a methicillin-susceptible Staphylococcus aureus (MSSA) infection had formed a large lobulated epidural abscess at L4-S1, with paraspinal muscle and intradural extension. One year after an L3-S1 laminectomy and two follow-up surgeries to treat hematomas and repair dural perforations, the patient was neurologically intact and walking independently.
The Rosinsky et al. case and the three other relevant “connections” from the JBJS Case Connector archive emphasize that prompt, definitive diagnosis and treatment of spinal infections–and enlisting the expertise of infectious-disease specialists–can lead to positive outcomes, while delay and clinical confusion can end catastrophically or fatally.
The goals of orthopaedic surgery for children with cerebral palsy (CP) include pain and spasticity reduction and improvements in hygiene and functional mobility. A multicenter study by Mulcahey et al. in the September 16, 2015 JBJS found that when assessing changes in lower-extremity mobility derived from orthopaedic surgery among 255 CP patients, computerized adaptive testing (CAT) was more sensitive than other commonly used instruments. Specifically, improvements in function detected by the CAT at 12 and 24 months following surgery were greater than the changes detected by the relevant domains of the oft-administered Pediatric Outcomes Data Collection Instrument (PODCI).
Interestingly, neither of those two instruments, nor the timed “up & go” test, performed well with patients at level II of the Gross Motor Function Classification System. Furthermore, the authors note that CAT results are based on parent reports and therefore provide perceived outcomes rather than direct measures. Nevertheless, this study yields sound evidence that the benefits of orthopaedic surgery in people with CP heretofore measured with less sensitive instruments are in fact substantial.
In less than a week from this posting, on October 1, 2015, ICD-10 diagnosis codes will debut. OrthoBuzz already reported on the 12-month leniency policy announced by the Centers for Medicare and Medicaid Services (CMS). In addition, during the home-stretch to the ICD-10 launch, CMS has published an online series of “cheat sheets” to help providers select at least the first few correct digits for the new codes. The guidance is primarily for family practitioners, but there are sections for back and neck pain and joint and limb pain that orthopaedists might find useful.
Keep in mind that private insurers are not obliged to follow CMS’s leniency lead in this area, although according to a Medscape.com article, Aetna, Humana, and Anthem have announced that they will. UnitedHealthcare is reportedly still mulling the issue, and Medicaid policies regarding how precise ICD-10 codes need to be will vary from state to state.
After October 1, please share your early ICD-10 experiences with OrthoBuzz by clicking on the “leave a comment” button in the box next to the title of this post. And good luck!
The September 16, 2015 JBJS study by Robinson et al. offers clear proof that many of our patients are sensitive to price when it comes to choosing where to go for arthroscopic surgery of the knee or shoulder. This phenomenon began at least a decade ago when employers began shifting the cost burden of health care coverage onto their employees. The findings from Robinson et al. confirm the increasing strength of this effect.
The authors analyzed administrative data from the California Public Employees’ Retirement System (CalPERS) to evaluate the impact of so-called “reference-based benefits” on patient choice for the setting of arthroscopy—hospital-based outpatient departments or freestanding ambulatory surgery centers (ASCs). Reference-based benefits require patients to pay the cost differential between an insurer-established “contribution limit” and the actual price charged by a facility.
Within two years of shifting to reference-based benefits, CalPERS-covered patients increased their utilization of ASCs by 14.3% for knee arthroscopy and by 9.9% for shoulder arthroscopy, with corresponding decreases in the use of hospital-based facilities. Meanwhile, CalPERS reduced overall spending on these procedures by 13%, and there were no significant before-and-after differences in 90-day complication rates.
These findings lead one to ask what added benefits patients receive from hospital-based outpatient surgery — Is it a safer environment or more convenient? Are the results more predictable? I think not, and on that basis the added charges are not justified.
Now that Robinson et al. have provided us with hard data on the impact of surgical-setting charges on patient behavior, we need to think about providing additional information that our patients would find helpful. We should, for example, move forward with increasing transparency on surgery fees and charges for outpatient visits, imaging, and durable medical goods. The time is right for us to do our part in eliminating this “black box” aspect of orthopaedic care.
At the same time, as commentators Kern Singh and Junyoung Ahn note, because payers will continue to define value according to their criteria, “orthopaedic surgeons should increase their involvement in this process to ensure the balance between outcome benefits and associated costs.”
Marc Swiontkowski, MD