COVID-19’s Musculoskeletal Manifestations

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

The SARS-CoV-2 coronavirus that causes COVID-19 induces the expression of several cytokines and signaling molecules. The impact of these inflammatory mediators on the lungs is the most lethal effect and thus has drawn the most attention. However, COVID-19 can have potentially longer-lasting (but less deadly) musculoskeletal effects.

COVID-19 has not been affecting people long enough to study its effects completely, but we do know that the virus predominantly infects type-II pneumocytes that line the respiratory epithelium. These cells express angiotensin converting enzyme-2 (ACE2) and transmembrane protease, serine 2 (TMPRSS2). Disser et al. note that TMPRSS2 is also expressed in muscle tissue, while only smooth muscle cells and pericytes express ACE2. They add that either ACE2 or TMPRSS2 is expressed in cartilage, menisci, bone, and synovium.

Myalgia has been reported to occur in COVID-19 patients 25% to 50% of the time. The effect on muscle can be severe, with more seriously ill patients having higher levels of creatine kinase. After recovery, patients often show decreased strength and endurance, but it is not clear how much of that is due to deconditioning or to persisting muscle effects. Although arthralgia can also occur, it is hard to separate those symptoms from myalgia, and both may exist at the same time.

Examination of muscle specimens from autopsies of COVID-19 patients shows significant muscle destruction. It is not clear whether the osteoporosis and osteonecrosis sometimes seen with SARS-CoV-2 is due to the virus’s direct effect on bone or to the steroids used to treat patients with more severe cases.

Because it is probable that inflammation associated with cytokine release has an impact on musculoskeletal tissues, orthopaedic surgeons are likely to be faced with a variety of musculoskeletal symptoms in post COVID-19 patients. Preliminary data suggest that rehabilitation for both strength and endurance is effective among patients who recover from COVID-19, but it is not clear whether return to former conditioning levels occurs. The use of immunotherapies, such as IL-1 and IL-6 inhibitors, may have a positive impact on initial treatment in these patients.

How Much Ulnar Lengthening in Kids with HME-Related Radial Head Dislocation?

Lengthening the ulna is a common method of treating radial head dislocations due to hereditary multiple exostoses (HME) in pediatric patients, but the optimal amount of ulnar lengthening remains unclear. In the June 17, 2020 issue of JBJS, Huang et al. demonstrate that using the proportional ulnar length of 1.1 as a guide to ulnar lengthening can promote spontaneous correction of the radial shaft deformity. The authors arrived at the 1.1 proportion by measuring the normal lengths of the ulna and radius in 20 pediatric patients of different age groups.

Huang et al. then treated 30 forearms (average patient age of 7.4 years) that had a radial head dislocation associated with HME. They excised the osteochondroma around the physis of the distal part of the ulna prior to lengthening. They then pulled the radial head down to the plane of the ulnar coronoid process with a Kirschner wire and lengthened the ulna to predicted proportional length using a modified Ilizarov frame. The technique also facilitated lengthening of the soft tissues of the elbow.

At the time of frame removal, reduction of the dislocated radial head was achieved in 28 forearms (93%). Forearm function also improved markedly, as did radial bowing and the radioarticular angle. The actual ulnar lengthening distance in these patients was greater than the predicted lengthening using the proportional method, but that contributed to the spontaneous remodeling of the radial shaft deformity, and there were no instances of wrist impingement.

The authors conclude that this study demonstrates that, in this clinical scenario, the “proportional ulnar length is a safe and effective parameter to use as the ulnar lengthening reference value.” But they also note that the small number of patients and the average follow-up of 63 months in this study should be expanded in future research.

Pledge from JBJS Regarding Race-Based Inequalities

The JBJS Board of Trustees published a statement today that addresses the global COVID pandemic and the worldwide demonstrations against systematic racism. As an organization, JBJS has pledged to take the following actions to promote racial equality in health care and in other aspects of human affairs that we influence:

  • In addition to the >100 articles already published in JBJS that explore health care disparities, The Journal will now prioritize manuscripts that delineate solutions to these widespread inequities.
  • JBJS will continue to support initiatives that increase minority representation in orthopaedic surgery programs throughout the US—including minority members of academic faculties. We will also publish data on the results of those efforts.
  • JBJS will look inward to promote greater diversity within our own organization.

We hope the readers of JBJS and OrthoBuzz are also taking action in their homes, workplaces, and communities to ensure that all people are treated fairly and equally.

Risk Factors for Failure after FAI Treatment

Orthopaedic surgeons continually seek to refine techniques to improve their patients’ surgical outcomes. Surgical treatments for femoroacetabular impingement (FAI) syndrome are no exception, and careful patient selection is also critical to the success of these interventions. In the June 17, 2020 issue of The Journal, Ceylan et al. analyzed a single-surgeon prospective database to identify risk factors for treatment failure after a particular hip-preservation surgery known as mini-open femoroacetabular osteoplasty (FAO). In this study, the authors defined “failure” as the eventual need for a total hip arthroplasty (THA) over a minimum 2-year follow-up.

The 749 procedures studied were performed between 2004 and 2016 and involved treatment of the femur, acetabular rim, labrum, and chondral surfaces if necessary. Labral repair was performed on all hips that had adequate healthy tissue, while those that did not were treated with partial or total excision of the labrum.

Sixty-eight  hips (9%) underwent THA. The patients who did not need a hip replacement were significantly younger (mean age of 33 years vs nearly 42) and were operated on after the surgeon had more experience. Other significant differences among the failure group included the duration of symptoms (twice as long, at 3.6 years), higher preop alpha angles, and a higher percentage of total labral resections performed.

Radiographic evidence of hip dysplasia was also a significant risk factor for failure, along with labral hypertrophy and acetabular retroversion (both of which may be considered proxies for volume-deficient acetabuli). After adjusting for covariates, Ceylan et al. found that less surgeon experience, older patient age, prolonged preoperative symptoms, increased medial joint space narrowing and Tonnis grade, and developmental hip dysplasia were all associated with a higher risk of failure after FAO surgery.

Although these findings do not represent results using the most up-to-date arthroscopic techniques for FAI treatment, they do highlight characteristics that can and should be discussed with patients with FAI when the subject of expected surgical outcomes arises during shared decision making.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

What’s New in Spine Surgery 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Jacob M. Buchowski, MD, selected the 5 most clinically compelling findings from the >30 studies summarized in the June 17, 2020 “What’s New in Spine Surgery.

Adult Spinal Deformity
A recent randomized controlled trial compared operative vs nonoperative treatment among 63 adult patients with symptomatic lumbar scoliosis. An additional 223 patients were included in an observational arm of the study. At 2 years, 64% of the randomized patients in the nonoperative group had crossed over to the operative group. In an as-treated analysis, surgery was associated with superior improvement, but the high crossover rate precludes making firm comparative conclusions.

Spinal Cord Injuries
—A small study of 3 subjects1 who had sustained a spinal cord injury investigated the delivery of spatially selective stimulation to posterior nerve roots innervating the lumbosacral spinal cord through an implantable pulse generator with real-time triggering capability. This method reestablished adaptive control over previously paralyzed muscles, and subjects were eventually able to walk or bike during spatiotemporal stimulation.

Cervical Myelopathy
—A prospective study of >700 patients with degenerative cervical myelopathy2 examined the impact of surgical management on neck pain outcomes. Using the Neck Disability Index at baseline and at 6, 12, and 24 months postoperatively, researchers found significant improvement in functional and pain scores that met or exceeded the minimum clinically important difference at all follow-up time points.

Lumbar Stenosis
—A retrospective study of >1,800 patients with symptomatic lumbar stenosis3 investigated whether pain improvements could be obtained surgically with decompression alone without fusion. At 1 year after surgery, decompression alone was associated with significant improvement in all patient-reported outcomes, suggesting that a concomitant fusion may not be required in such cases.

Opioid Consumption
—A retrospective study of nearly 29,000 patients4 examined the effects of chronic preoperative opioid therapy on medium- and long-term outcomes after lumbar arthrodesis surgery. Postoperatively, chronic opioid use prior to surgery was associated with an increased risk of 90-day emergency department visits and prolonged 1- and 2-year narcotic use.

References

  1. Wagner FB, Mignardot JB, Le Goff-Mignardot CG, Demesmaeker R, Komi S, Capogrosso M, Rowald A, Se´añez I, Caban M, Pirondini E, Vat M, McCracken LA, Heimgartner R, Fodor I, Watrin A, Seguin P, Paoles E, Van Den Keybus K, Eberle G, Schurch B, Pralong E, Becce F, Prior J, Buse N, Buschman R, Neufeld E, Kuster N, Carda S, von Zitzewitz J, Delattre V, Denison T, Lambert H, Minassian K, Bloch J. Courtine G. Targeted neurotechnology restores walking in humans with spinal cord injury. Nature. 2018 Nov;563(7729):65-71. Epub 2018 Oct 31.
  1. Schneider MM, Tetreault L, Badhiwala JH, Zhu MP, Wilson J, Fehlings MG. 42. The impact of surgical decompression on neck pain outcomes in patients with degenerative cervical myelopathy: results from the multicenter prospective AOSpine studies. Spine J. 2019 Sep;19(9):S21.
  2. Bech-Azeddine R, Fruensgaard S, Andersen M, Carreon LY. 215. Outcomes of decompression without fusion in patients with lumbar spinal stenosis with back pain. Spine J. 2019 Sep;19(9):S106.
  3. Eisenberg JM, Kalakoti P, Hendrickson NR, Saifi C, Pugely AJ. 142. Impact of preoperative chronic opioid therapy on long-term outcomes, reoperations, complications and resource utilization after lumbar arthrodesis. Spine J. 2019 Sep; 19(9):S68-9.

Reoperation Rates for Wrist-Arthritis Treatments

With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.

In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration  data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.

Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).

Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Revision Shoulder Arthroplasty: IV or Oral Antibiotics?

Surgeons performing revision shoulder arthroplasty typically order postoperative antibiotics to be administered while they wait for results from intraoperative cultures. Based on their index of suspicion from preoperative exams and intraoperative observations, they order either intravenous (high suspicion of infection) or oral (low suspicion) antibiotics during the waiting period. In the June 3, 2020 issue of JBJS, Yao et al. report on a retrospective review of 175 patients who underwent revision shoulder arthroplasty, finding that surgeons’ presumptive choice of antibiotic type matched the culture results in 75% of the cases.

Among the 175 patients in the study, IV antibiotics were initiated in 62, while 113 patients received oral antibiotics. Cultures from 49 of the 62 patients started on IV antibiotics came back positive, and cultures from 83 of the 113 patients started on oral antibiotics came back negative. Treatment of patients whose initial antibiotic regimen did not match culture results was modified accordingly.

After multivariate analysis Yao et al. found that male sex, prior ipsilateral infection, and intraoperative presence of a humeral membrane were 3 independent predictors of surgeons initiating IV antibiotics. Antibiotic-related adverse events (including GI, dermatologic, and allergic reactions) occurred in 19% of the patients. Not surprisingly, the rate of these complications was highest among those receiving IV antibiotics.

Although the surgeons’ empirical initiation of antibiotic administration route was “correct” 75% of the time, that still left 25% of the patients needing modification of therapy based on culture results. While the authors observe that their study was  not designed “to report the relative effectiveness of the 2 antibiotic protocols in minimizing the risk of recurrent infection,” their findings confirm that preoperative and intraoperative observations can help surgeons select the “right” type of antibiotic without culture results—and that is heartening.

TKA Cost Efficiency Is Improving, But We Can Do Better

Wide variability in the cost and quality of health care in the US has led some to describe our system as “uniquely inefficient.” Consequently, we continue to study variability intensely, especially in the realm of joint arthroplasty. In the June 3, 2020 issue of The Journal, Schilling et al. elegantly analyze the variations in 90-day episode payments made by Medicare Part A for total knee arthroplasty (TKA) from 2014 to 2016. In so doing, they provide a snapshot of hospital cost performance and, just as importantly, they offer a methodology by which to measure future hospital-level cost performance with this very popular surgery.

The authors reviewed >700,000 TKAs in the Medicare population at a time prior to the full implementation of the Comprehensive Care for Joint Replacement (CJR) model, and they ranked >3,200 hospitals within 9 US regions to determine cost performance.  Schilling et al. found that during those 3 years, the mean Medicare episode payment for TKA decreased significantly, due almost entirely to a >$1,500 per-case decrease in post-acute care payments, which included lower costs for skilled nursing facilities and inpatient rehabilitation. Also decreasing during that same period were length of hospital stay and 90-day readmission rates.

These findings highlight the improvements in care and cost efficiency that were occurring even before implementation of the CJR. In a Commentary on this study, Susan Odum, PhD suggests that “the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI [Bundled Payments for Care Improvement] program,” an alternative payment model that Medicare rolled out beginning in 2013.

On the other hand, the authors also reveal a persistently high degree of variability in episode payments and resource utilization both across and within geographic regions. This strongly suggests the possibility of further improvement. Regardless of which, if any, alternative payment model we participate in, everyone in the orthopaedic community should think about how to become more efficient in our delivery of musculoskeletal care. And this study provides a conceptual framework and benchmarks for identifying where the room for improvement is.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

PROM ‘Crosswalks’ Are a Big Step Forward

Patient-reported outcome measures (PROMs) for orthopaedic procedures have long been used in clinical research. In the last decade, the use of PROMs has expanded to include quality-of-care assessments and, in some healthcare systems, to help calculate costs and reimbursements. All this has made PROMs increasingly visible to patients.

There are several validated and widely used PROMs for hip and knee arthroplasty. One problem with those is that the data from one PROM are not interchangeable with data from another. That disconnect limits the opportunity for meaningful data aggregation and thwarts large-scale population research.

In the June 3, 2020 issue of The Journal, Polascik et al. tackle this problem head-on. They report on a “crosswalk” system that allows back-and-forth conversion between 4 of the most commonly used PROMS—the Oxford hip and knee scores and the HOOS and KOOS short-form scores. The authors developed this tool by applying sophisticated statistical methods to data from a large cohort of hip and knee arthroplasty patients. The accuracy of the 4 crosswalks Polascik et al. developed was substantiated when they found minimal differences between the means of the known and crosswalk-derived scores.

This practical tool for converting scores is a substantial advance in patient-reported outcomes research. It will further facilitate the pooling of data for use in future clinical research, quality-of-care initiatives, and reimbursement systems. Patients, surgeons, researchers, and health systems alike all stand to benefit greatly.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Screening Orthopaedic Patients for Asymptomatic COVID-19

During the initial surge of COVID-19, symptomatic patients were thought to be mainly responsible for spreading the virus, and guidelines therefore focused on identifying and isolating patients with fever, cough, or shortness of breath. However, as the asymptomatic spread became better understood, the need for more widespread, consistent molecular testing protocols became evident—and this is especially important now that elective orthopaedic surgery has resumed. Performing a surgical procedure on an asymptomatic patient with COVID-19 could lead to contamination of the operating room and other hospital zones, possibly infecting staff and other patients.

In the latest JBJS fast-track article related to COVID-19, Gruskay et al. describe a protocol for universal PCR swab testing of all orthopaedic surgery admissions at their New York City hospital during the 3 weeks between April 5, 2020 and April 24, 2020. At that time, only urgent orthopaedic procedures were being performed. Swab testing of 99 patients revealed a high rate of COVID-19 infections—the majority of which were in patients with no symptoms. With these published findings, the authors “hope to… make a case for nasopharyngeal testing of all preoperative patients.”

During those 3 weeks in April, 7 (58.3%) of the 12 patients who tested positive for COVID-19 had no symptoms consistent with the infection on presentation, and only 1 of those patients had pneumonia that appeared on a preoperative chest radiograph. Three asymptomatic patients who tested positive developed postoperative hypoxia, with 2 requiring intubation.

In recommending routine preoperative PCR testing for orthopaedic patients, the authors acknowledge the high specificity but only moderate sensitivity of the swab test, “but few other practical options exist,” they say. Evidence suggests that CT evaluation is the most accurate diagnostic test for COVID-19 pneumonia, but its use for screening is impractical. Chest radiography is more widely available, faster, and cheaper and emits less radiation than CT, but the sensitivity for diagnosing COVID-19 pneumonia with radiographs is reported as only 70%.