What’s New in Foot and Ankle 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, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the 5 most clinically compelling findings from the >60 studies summarized in the May 20, 2020 “What’s New in Foot and Ankle Surgery.”
Total Ankle Replacement
—An analysis of a consecutive series of 278 total ankle replacemments1 found that the overall incidence of postoperative complications was 41.7%. However, the clinical outcome was affected in only 7.6% of these cases, as most complications were minor.
Syndesmotic Injuries
—A meta-analysis (total n = 397) found that functional outcomes and complications were similar after suture-button fixation and screw fixation for syndesmotic injuries.2 Time to full weight-bearing, however, was faster among patients receiving suture-button fixation.
Osteochondral Lesions of the Talus
—A prospective cohort study3 examined 101 patients with osteochondral talar lesions of <1.5 cm2. After a minimum follow-up of 36 months, patients treated with microfracture alone (n = 52) and patients treated with microfracture + autologous iliac crest bone marrow aspirate concentrate (BMAC) (n = 49) both reported significant improvement in pain, sport, and activities of daily living. The revision rate was significantly lower in the microfracture + BMAC cohort.
Plantar Fasciitis
—A randomized controlled trial4 compared stretching alone (n = 20) with stretching + proximal medial gastrocnemius recession (n = 20) in patients with >12 months of plantar heel pain. The operative group had significantly greater improvements in functional and pain scores and in forefoot plantar pressure at 12 months of follow-up. Achilles function and calf weakness were similar in both groups.
Clubfoot
—A retrospective case series reviewed 220 feet among 145 Nepalese children who had been treated for idiopathic clubfoot with the Ponseti method. At a minimum of 10 years of follow-up, 95% of the 220 feet achieved a plantigrade foot. Surgical treatment, typically a percutaneous Achilles tendon release, was required in 96% of the feet.
References
- Clough TM, Alvi F, Majeed H. Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature. Bone Joint J.2018 Oct;100-B(10):1352-8.
- Chen B, Chen C, Yang Z, Huang P, Dong H, Zeng Z. To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: a meta-analysis. Foot Ankle Surg.2019 Feb;25(1):63-70. Epub 2017 Aug 18.
- Murphy EP, McGoldrick NP, Curtin M, Kearns SR. A prospective evaluation of bone marrow aspirate concentrate and microfracture in the treatment of osteochondral lesions of the talus. Foot Ankle Surg.2019 Aug;25(4):441-8. Epub 2018 Feb 22.
- Molund M, Husebye EE, Hellesnes J, Nilsen F, Hvaal K. Proximal medial gastrocnemius recession and stretching versus stretching as treatment of chronic plantar heel pain. Foot Ankle Int.2018 Dec;39(12):1423-31. Epub 2018 Aug 22.
Surgery to Repair the Hip’s ‘Rotator Cuff’
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.
Symptoms from gluteus medius tendon tears are common in people older than 50 years, but they are hard to distinguish from referred pain due to lumbar spine conditions or hip disorders such as osteoarthritis and femoroacetabular impingement. Because conservative measures are often effective, surgical remedies are not commonly discussed in the literature.
An anatomical study of the gluteus medius tendon found that the posterior part of the tendon has a fan-like shape and converges onto the superoposterior facet of the greater trochanter. The anterolateral part runs posteroinferiorly toward the lateral facet of the greater trochanter. Both the posterior and anterolateral parts insert via fibrocartilage. Given the nonuniform structure of this tendon, the thin anterolateral part may be more prone to tears than the thick posterior part.
In another recent study, a single surgeon described his experience with 185 consecutive gluteus medius tendon tear repairs.1 Tendon changes were confirmed preoperatively on MRI. Roughening of all appropriate surfaces preceded multiple-suture repair through bone holes, with sutures in line with the tendon segment being attached. Of the 185 patients, 165 completed 5- to 10-year phone follow-ups. The average age was 69 and 92% were female. There was no histological evidence of bursitis in any case. Only 9 patients reported worse Oxford Hip Scores at the 5-year follow-up; deep vein thrombotic events occurred in 4% of patients despite prophylaxis. Other common gluteus medius tendon repair techniques include utilization of suture anchors through a mini-open2 or arthroscopic approach.
Unlike degenerative rotator cuff tears of the shoulder, both incomplete and complete acute tears of the gluteus medius respond well to repair surgery. More advanced degenerative gluteus medius tendon changes do not respond as well. It is not clear what the differences are in the mechanical and biochemical mechanisms of rotator cuff and gluteal tendon changes that make surgery to repair the former seemingly less successful than surgery to repair the latter. Nevertheless, these four studies show promise for surgical interventions that have a reasonable chance of being effective, with relatively low risk.
References
- Fox OJK, Wertheimer G, Walsh MJ. Primary Open Abductor Reconstruction: A 5 to 10-Year Study. J Arthroplasty. 2020 Apr;35(4):941-944. doi: 10.1016/j.arth.2019.11.012. Epub 2019 Nov 14. PMID: 31813815
- Caleb M Gulledge, Eric C Makhni. Open Gluteus Medius and Minimus Repair With Double-Row Technique and Bioinductive Implant Augmentation. Arthrosc Tech 2019 May 17;8(6):e585-e589. doi: 10.1016/j.eats.2019.01.019. eCollection 2019 Jun. PMID: 31334014 PMCID: PMC6620622
JBJS Announces 2019 EST Award Winners
JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) article, and the other for the best Key Procedures (KP) video published during each calendar year.
We are pleased to announce the winners for 2019:
- Editor’s Choice Technique Award:
Patellofemoral Arthroplasty
by Anders Odgaard, MD, DMSc, FRCS; Jonathan Eldridge, MD, FRCS; and Frank Madsen, MD - Editor’s Choice Video Award:
Repair of Tibial Plateau Fracture (Schatzker II)
by Dylan T. Lowe, MD; Michael T. Milone, MD; Leah J. Gonzalez, BS; and Kenneth A. Egol, MD
Both articles are freely available online until the end of August 2020.
Submissions for the 2020 EST Awards are currently being accepted.
Open-Access JBJS Supplement: Pain Management Research
In November 2019, OrthoBuzz promised readers more details from the Pain Management Research Symposium held that month (see related post), which was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Those details are now available in the form of a JBJS Supplement containing 12 articles generated from that convening of > 30 orthopaedic researchers and journal editors. The Symposium focused on the unique challenges of designing studies that will answer pressing questions about pain management related to musculoskeletal conditions and procedures.
The content of this open-access Supplement ranges from subspecialty-specific considerations in pain management to “complementary medicine” approaches. It culminates in 7 key “Recommendations for Pain Management Research,” all targeted to identifying effective pain-management strategies, not just elimination of opioids. Among those recommendations are the following:
- Define all terms (such as “long-term opioid use”) precisely.
- Quantify opioid use in morphine milligram equivalents (MMEs), and state how MMEs were calculated.
- Precisely define the study population (including age, sex, and socioeconomic and cultural characteristics).
- Mental/emotional risk factors–including depression, catastrophizing, expectations, and coping ability–should be studied.
- Outcome measures should be patient-related, not just the number of pills taken.
JBJS would again like to thank NIAMS for its support and all Symposium participants and Supplement authors for their time and energy.
Preop Nerve Blocks for Hip Fractures – Sooner Is Better
The benefits of peripheral nerve blocks for pain control and decreased use of opioids has been well-established for several orthopaedic procedures. In the May 20, 2020 issue of The Journal, a prospective cohort study by Garlich et al. shows that administering such a block earlier rather than later significantly benefits elderly patients awaiting surgery for a hip fracture.
The authors looked at whether the time to block (TTB) with a fascia iliaca nerve block (FIB) in a cohort of 107 patients who sustained a hip fracture affected preoperative opioid consumption and postoperative pain scores. They also examined the relationship between TTB and length of stay and adverse events related to opioids. All FIBs were performed between the time of emergency department arrival and ≥4 hours prior to surgery. Those parameters allowed time for the block to work and also time for the patients in this cohort to request pain medication.
Preoperatively, 72% of all opioid consumption took place prior to block placement. Patients experiencing a faster TTB consumed fewer opioids preoperatively and also on postoperative days 1 and 2, although the day-2 differences were not statistically significant. More specifically, Garlich et al. found a 63.7% reduction in the median preoperative opioid consumption in those with a TTB <8.5 hours from the time of arrival, relative to those whose TTB was ≥8.5 hours.
In addition, patients with a TTB <8.5 hours had significantly lower pain scores on postoperative day 1, and their hospital stays were significantly shorter than those who received blocks ≥8.5 hours after arrival (4.0 days versus 5.5 days). There were no differences in opioid-related adverse events between the TTB groups, although commentator Dr. Patrick Schottel notes that the study was underpowered to definitively discern those between-cohort differences.
Overall, this important study shows that early preoperative FIB reduces perioperative opioid consumption in geriatric patients with hip fractures, in addition to decreasing their pain scores and length of hospital stay. Further investigation is needed to determine the optimal timing for administering preoperative blocks in this vulnerable population.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
High-Level Clinical Research in Developing Countries? Yes!
Generally speaking, orthopaedic surgeons in low-resourced environments deliver the best care for their patients with skill, creativity, and passion. These surgeons are accustomed to scrambling for implants and other tools and to working around limited access to operating theaters and anesthesia services. Their everyday struggles usually leave little energy or time to even think about clinical research.
However, in the May 20, 2020 issue of The Journal, Haonga and colleagues prove that, with a “little help from their friends,” it is possible to conduct Level I research while treating patients in a resource-limited setting. They enrolled and followed 221 patients with open tibial fractures (mostly males in their 30s injured in a road-traffic collision) and randomized them to treatment with either uniplanar external fixation or intramedullary (IM) nailing. The nails were supplied by SIGN Fracture Care International, a not-for-profit humanitarian organization that provides specially designed IM nails that can be used without image intensification to hospitals in developing countries around the world. (See related OrthoBuzz post.)
The research was done in Dar es Salaam, Tanzania, in collaboration with trauma surgeons and epidemiologists from the University of California San Francisco, which has a long-standing relationship with Tanzania’s Muhimbili National Hospital. At the 1-year follow-up, there were no significant between-group differences in primary-outcome events—death or reoperation due to deep infection, nonunion, or malalignment. IM nailing was associated with a lower risk of coronal or sagittal malalignment, and quality-of-life (QoL) scores favored IM nailing at 6 weeks, but QoL differences dissipated by 1 year.
Just as important as the clinical findings, these investigators proved that it is possible to do high-level research in centers with high patient volume and limited resources. Future patients will benefit because the clinicians now have better information to share regarding expectations for functional recovery and risk of infection. Physicians and other healthcare professionals benefit because data like this help improve their analytical skills and become more discerning appraisers of the published literature. With strong internal physician leadership and a little outside support, Haonga et al. have convinced us that prospective—and even randomized—research is possible in these special places.
Finally, SIGN deserves our support as a true champion of orthopaedic surgeons working in under-resourced environments. In addition to providing education and implants, SIGN surgeons are required to report their cases through the SIGN Surgical Database—which encourages the research mindset and helps SIGN surgeons improve tools and techniques for better patient outcomes.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
May 2020 Article Exchange with JOSPT
For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of May 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Athletes with Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria than Athletes with Hamstring Tendon Autograft or Soft Tissue Allograft.”
Although the title reveals the findings of this retrospective cohort study, the authors emphasize that “athletes in the allograft and HT groups may be at higher risk of sustaining another knee injury when they return to sport…than those in the BPTB group.” Also, all 79 participants in the study were athletes planning to return to level 1 or 2 sporting activities, so these findings may not be generalizable to all athletes.
COVID-19 Patients: Better Breathing After Fracture Surgery
COVID-19 infections spread rapidly in northern Italy from February to April of 2020. During that time, the orthopaedic unit at Humanitas Gavazzeni Hospital in Bergamo focused on elderly patients with both a femoral neck fracture and COVID-19. In a fast-tracked JBJS study, Catellani et al. report on what happened to 16 COVID-19-positive patients who were admitted to the hospital’s emergency department with a proximal femoral fracture:
- 3 patients died from severe respiratory insufficiency and multiple-organ failure before surgery could be considered or performed.
- 10 patients underwent fracture surgery on the day after admission; 3 had surgery on the third day after admission to allow washout of direct thrombin inhibitors.
- Oxygen saturation improved in all patients who underwent surgery except 1
- Hemodynamic and respiratory stability was achieved in 9 patients at an average of 7 days postsurgery.
- 4 patients who underwent surgery died of respiratory failure—1 on the first day after surgery, 2 on the third day after surgery, and 1 on the seventh day after surgery.
In general, the advantages of early treatment of proximal femoral fractures in the elderly include early mobilization and better pain control. On the other hand, orthopaedists consider severe respiratory insufficiency to be a contraindication to anesthesia and surgery. The anesthesiology team working with Catellani et al. recommended early surgery in these patients if their oxygen saturation was >90% and their body temperature was <38°C. Spinal anesthesia was used for all patients to avoid sedation and was combined with a peripheral femoral nerve block to achieve better pain management.
The authors concluded that most of these COVID19-positive patients who presented in less critical condition and underwent carefully planned and executed surgery for proximal femoral fractures experienced a notable stabilization of their respiratory parameters.
A Primer on Coding and Documentation for Telemedicine
Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.
The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”
Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.
It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”
Virtual-Meeting Best Practices from OrthoEvidence
In addition to medical appointments between physicians and patients, many medical meetings and conferences have moved to online platforms due to the COVID-19 pandemic. That prompted the OrthoEvidence team, led by renowned orthopaedic surgeon and researcher Mohit Bhandari, MD, to publish a 32-page, downloadable resource titled “Best Practice Recommendations for Virtual Meetings.”
The document—developed from extensive reviews of the literature and private and public-sector documents, consultation with experts, and stakeholder surveys—is designed to help guide healthcare and academic groups as well as policymakers and funders.
The guidelines are organized into 5 sections:
- Preplanning Considerations
- Planning
- Accomplishing goals
- Response
- Engaging the audience for future activities
A virtual-meeting planning checklist, a helpful table of virtual-meeting platform vendors, and many other practical resources are included in the document’s 6 Appendices.
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