This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) highlights the case of a 34-year-old man who presented with a 1-month history of hand and wrist pain after driving his golf club into the ground during a swing. Anteroposterior (AP) and lateral radiographs of the wrist are shown, and findings from the physical exam are described.
The Image Quiz reviews the anatomy of the wrist, focusing on the symptoms and mechanisms of hamate injuries. The quiz question is: After standard AP and lateral radiographs, which imaging modality or view would be most helpful in arriving at a definitive diagnosis? Options for treating a fracture of the hook of the hamate are also discussed.
In a population-based epidemiological study published in the July 6, 2016 Journal of Bone & Joint Surgery, Tibor et al. found that from 2007 to 2014:
- Many ACL-reconstruction surgeons changed from a transtibial approach to either an anteromedial portal or lateral approach for femoral-tunnel drilling.
- Most did not substantially change the types of grafts they used.
- Many eschewed first-generation bioabsorbable implants in favor of biocomposite fixation devices.
The authors found no change in cumulative revision rates during the study period.
Tibor et al. analyzed information from 21,686 primary ACL reconstructions housed in a Kaiser Permanente registry that collected data from surgeries performed in 33 hospitals by 246 surgeons in urban, rural, and suburban settings in three Western US states. This wide-ranging data set, the authors say, “increases the generalizability of our findings to other community-based surgeons.”
The authors admit, however, that the epidemiological nature of the study “offers only limited insight into associated outcomes,” and they were unable to analyze cost trends because the registry does not capture cost data.
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. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Theodore Choma, MD and Darrel Brodke, MD, co-authors of the June 15, 2016 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies they cited.
–A Level-I meta-analysis of 11 RCTs showed that tranexamic acid significantly lowered perioperative blood loss and transfusion requirements during spine surgery, with no associated increased incidence of heart attack or pulmonary embolism.1
Adult Spinal Deformity
–An analysis of prospective registry data from 766 adult patients with spinal deformity found that health-related quality-of-life scores for those patients prior to any intervention were lower than pre-intervention scores for patients with arthritis, chronic lung disease, diabetes, and congestive heart failure. The authors concluded that the global burden of spinal deformity warrants research and health-policy attention comparable to that given to other high-burden conditions.2
–A double-blind RCT of patients presenting to the emergency department with acute nonradicular low back pain found no difference in one-week disability scores among three groups: those given naproxen + cyclobenzaprine; those given naproxen + oxycodone/acetaminophen; and those given naproxen + placebo. The findings led the authors to conclude that adding those drugs to naproxen provides no clinical benefit.3
–A post-hoc analysis of SPORT data focused on patients ≥80 years old with degenerative spondylolisthesis found that operative treatment conferred a significant benefit relative to nonoperative treatment. The researchers found no significant increases in postoperative complication or mortality rates in this patient population compared with younger post-op patients.
–A 16- to 22-year follow-up of a previous randomized trial of 47 patients from the 1990s who had been randomized to operative or nonoperative treatment after a stable thoracolumbar burst fractures found that those treated nonoperatively had less pain and better function than those who had been treated operatively.
- Cheriyan T,Maier SP 2nd., Bianco K, Slobodyanyuk K, Rattenni RN, Lafage V, Schwab FJ, Lonner BS, Errico TJ. Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. Spine J. 2015Apr 1;15(4):752-61. Epub 2015 Jan 21.
- Pellisé F, Vila-Casademunt A, Ferrer M, Domingo-Sàbat M, Bagó J, Pérez Grueso FJ, Alanay A, MannionAF, Acaroglu E;European Spine Study Group, ESSG. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015 Jan;24(1):3-11. Epub 2014 Sep 14.
- Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
OrthoBuzz regularly brings 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 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.
When Walter Putnam Blount, MD described “Tibia Vara: Osteochondrosis Deformans Tibiae” in the January 1937 issue of The Journal of Bone & Joint Surgery, he probably did not realize that this mouthful of a term would become known simply as “Blount disease.” With a keen interest in children’s limb and spinal deformities, Blount was a pioneer pediatric deformity surgeon. He spent most of his career at the Children’s Hospital in Milwaukee and was clearly ahead of his time.
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Additionally, he parsed out 16 other cases of genu varum that previous authors had reported as being secondary to rickets, infection, or other etiologies. In vivid detail, including tracings of these other patients’ radiographs, Blount corroborated that this newly described entity was indeed something different. He supplemented his research with histologic specimens from the affected growth plate and surrounding unossified cartilage of the proximal tibia.
Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Although most of his Caucasian patients in the 1937 study were not overweight, with the changing U.S. demographics and the prevalence of childhood obesity, his suggestion of a genetic and a mechanical basis for this growth-plate disorder remains plausible.
Based on the age of onset of the deformity, Blount recognized that there were two distinct forms of tibia vara, which he classified as infantile and adolescent. While the radiographs in the article only show the frontal images, he clearly documented the associated axial plane deformities with internal tibial torsion and ipsilateral shortening. Though Blount was a big proponent of the Milwaukee brace for managing spinal deformities in children, he seemed disenchanted with using orthoses to treat tibia vara. He instead advocated surgical correction via a valgus realignment proximal tibial osteotomy, a recommendation that remains relevant to this day.
Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” as another way of treating pediatric limb deformities. Interestingly, more than a decade after his description of tibia vara, Blount published another masterpiece in JBJS, “Control of Bone Growth by Epiphyseal Stapling.” Prior to this time, (hemi)epiphyseodesis was largely performed by the Phemister technique, with permanent ablation of the growth plate. By recognizing that physeal growth can be harnessed to correct angular deformities by inserting removable implants such as staples across the growth plate, Walter Blount, through these two classic JBJS articles and various other contributions, outlined essentially all viable options that are currently available to treat this disorder that fittingly bears his name.
In his presidential address to the American Academy of Orthopedic Surgeons in January 1956, Blount noted, “I should rather be remembered as a thoughtful surgeon than as a bold one.” His wish has indeed come true.
Sanjeev Sabharwal, MD, MPH
JBJS Deputy Editor
The July 6, 2016, edition of The Journal of Bone & Joint Surgery features a large case-cohort study that may help older patients and clinicians decide whether to use bone morphogenetic protein (BMP) as an adjunct to lumbar arthrodesis. Among Medicare patients aged 65 years and older, Beachler et al. found that BMP use was not associated with the following:
- Overall cancer risk
- Increased risk of individual cancer types
- Increased risk of cancer in people who had cancer prior to undergoing lumbar arthrodesis
- Increased mortality after a cancer diagnosis
BMP was used in 30.7% of >3,600 lumbar-arthrodesis patients analyzed, and the lack of association between BMP use and cancer held whether patients received the growth factor as part of an FDA-approved anterior lumbar interbody fusion or as an off-label application.
In an accompanying commentary, Singh et al. laud the authors for designing a study that was not only well-powered but also analyzed risk among those with a medical history of cancer. The commentators emphasize, however, that the median follow-up in this study was 2.4 years, leading them to wonder “whether this time frame is sufficient to evaluate the impact of BMPs on carcinogenesis.”
Until a large, prospective, randomized trial on this subject is conducted, Singh et al. say, “the decision to use BMPs should be made on the basis of sound clinical judgment by the treating physician after a full disclosure of the potential risks to the patient.”
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher E. Gross, MD, in response to the May 18, 2016 JBJS Specialty Update on Foot and Ankle Surgery.
Ankle arthritis occurs along a spectrum of severity—ranging from minor cartilage lesions to significant degenerative disease.
To preserve ankle function and to prevent possible evolution into arthritic changes, osteochondral lesions should be treated as soon as they become symptomatic. In one prospective cohort study summarized by Lin and Yeranosian in the May 18, 2016 JBJS Specialty Update, thirty patients with talar osteochondral lesions underwent arthroscopic implantation of bone marrow-derived cells onto a collagen scaffold. Patients who received adjunctive biophysical stimulation by pulsed electromagnetic fields (PEMFs) had higher AOFAS scores at one year post-operatively than those who did not.1 The proposed explanation for this outcome is that PEMFs decrease inflammatory cytokines and help differentiate stem cells into chondrocytes.
Total ankle replacements (TARs) have become a viable surgical option for patients with end-stage ankle arthritis. In a study comparing patients undergoing TAR with those undergoing arthrodesis,2 TAR patients had higher expectations of their surgery than fusion patients and were more likely to have higher satisfaction scores post-operatively. In a functional comparison of TAR and arthrodesis, Jastifer, et al. found that patients who received a TAR had an easier time walking uphill and down/upstairs.3 In another study evaluating functional biomechanics following TAR surgery, groups whose procedure included Achilles tendon lengthening were compared to those who had TAR alone.4 There were no between-group differences in functional outcomes or gait mechanics.
In a study comparing results and complications of TAR in patients with rheumatoid arthritis to patients who had ankle replacements due to either traumatic or primary arthritis, the authors found similar functional outcomes and complication rates.
Despite these many examples of TAR success in the recent literature, the procedure is not without its shortcomings. Rahm, et al.5 compared patients who underwent primary ankle fusion to those who underwent salvage ankle arthrodesis because of a failed TAR. Those who had a salvage procedure had more pain and decreased functionality compared to those who underwent a primary fusion.
Christopher E. Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston.
- Cadossi M, Buda RE, Ramponi L, Sambri A, Natali S, Giannini S. Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study. Foot Ankle Int. 2014 Oct;35(10):981-7.
- Younger AS, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, et al. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
- Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int. 2015 Jan;36(1):11-7.
- Queen RM, Grier AJ, Butler RJ, Nunley JA, Easley ME, Adams SB, Jr., et al. The influence of concomitant triceps surae lengthening at the time of total ankle arthroplasty on postoperative outcomes. Foot Ankle Int. 2014 Sep;35(9):863-70.
- Rahm S, Klammer G, Benninger E, Gerber F, Farshad M, Espinosa N. Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis. Foot Ankle Int. 2015 Apr;36(4):349-59.
The National Library of Medicine has accepted JBJS Reviews for indexing in MEDLINE/PubMed.
Launched in November 2013 and edited by Thomas A. Einhorn, MD and a distinguished editorial board, JBJS Reviews is an innovative, continuously published online review journal from the publishers of The Journal of Bone & Joint Surgery.
Each weekly posting of JBJS Reviews content updates the orthopaedic community on important topics in a concise, time-saving manner. Comprehensive reviews, special features, and integrated CME provide musculoskeletal clinicians with valuable perspectives on surgical practice and the latest advances in the field within twelve subspecialty areas.
If you are not already a JBJS Reviews subscriber, click here to learn more.
In the July 6, 2016 issue of The Journal, Weinberg at al. carefully measure the rotational profile of 600 cadaveric human forearm bones. The precision of these measurements is outstanding and sets a new standard for this type of investigation. The authors put real numbers on the rotational relationships between the radius and ulna that Evans first proposed in JBJS in 1945—and that many surgeons have relied on for intraoperative assessments of forearm rotational alignment since then.
What this investigation documents is the wide range of rotational profiles in the human forearm, with broad standard deviations. It confirms what all clinicians experience every day—each patient’s anatomy is different. There is commonality in hard- and soft-tissue structure overall, but the range of size, shape, density, length, and rotation is patient-specific and highly variable.
Whether closed, percutaneous, or open methods are applied, the skill and experience of the surgeon trump radiographic rules/tips/guidelines. As is often said with fracture reduction, the surgeon is responsible for 80% of the outcome. Studies comparing different casting methods or fixation devices provide useful information that address the remaining 20%, but surgical technique and surgeon experience/judgment are the major determinants.
We must always remember that each patient is not only emotionally and socially unique, but also anatomically unique. Our job is to restore their individual anatomy to the best of our clinical ability. I am therefore not sure that repeating high-precision measurements of other osseous structures—only to re-confirm anatomic variability—will have much ultimate value for our community.
Marc Swiontkowski, MD
The Editors of The Journal of Bone & Joint Surgery are pleased to announce the launch of JBJS Open Access. This new online-only journal gives authors an open-access option bolstered by the outstanding service and brand of excellence that JBJS has delivered for more than 125 years. And readers worldwide will benefit from expanded access to the best clinical and basic-science content about musculoskeletal health and injury care.
JBJS Open Access Co-editors Dr. Eng Lee and Dr. Robin Richards are not only expert basic-science and clinical researchers, but together they have more than 60 years of experience in scholarly publishing.
Click here for more information about this latest step in our continuing effort to meet the evolving needs of authors and readers.
Marc Swiontkowski, MD
BMJ recently published two studies of interest to orthopaedists:
- After analyzing data from more than 200 cardiovascular, orthopaedic, and neurologic devices approved in both the US and European Union (EU), Hwang et al. found that those approved in the EU first were nearly three times as likely to trigger a safety alert or experience a recall than those first approved in the US. Finding further that trial results were published for fewer than half of approved devices considered “major innovations,” the authors call for “greater regulatory transparency” so physicians and patients can make better-informed decisions. Interestingly, Figure 2 in this study showed that the FDA approval time for orthopaedic devices was faster than ortho-device approval times in the EU. However, a JBJS study earlier this year found that devices approved via the FDA’s “quick” 510(k) process were 11.5 times more likely to be recalled than those cleared through the longer and more stringent FDA pathway.
- In the second BMJ article, a registry-based case-control study, Abrahamsen et al. found that the long-term use of the bisphosphonate alendronate does not increase the risk for atypical femoral fractures (either subtrochanteric or femoral shaft), while protecting against hip fractures. After applying some sophisticated statistical analyses, the authors estimated that 38 patients with ≥5 years of alendronate adherence would need to be treated for an additional 5 years to prevent one hip fracture, while 1449 similar patients would need to be treated to cause an atypical femoral fracture. Click here for more OrthoBuzz coverage of the relationship between bisphosphonates and atypical femoral fractures.