Along the spectrum of early and late adopters in medicine, most orthopaedic surgeons fall in the middle. They wait for science to prove the efficacy and safety of an innovation, carefully review the published studies regarding that innovation, and adopt it if it will improve their patients’ outcomes.
In the December 4, 2019 issue of JBJS, Jules-Elysee et al. compare tranexamic acid (TXA) administered intravenously (IV) versus topically in a double-blinded, randomized controlled trial (RCT) of patients undergoing primary total knee arthroplasty (TKA). Level-I evidence is rare in the orthopaedic literature, so when a well-performed RCT comes out, we should closely evaluate its findings.
A potent antifibrinolytic, TXA has been shown in multiple studies to decrease blood loss associated with major orthopaedic procedures. However, there are persistent (but not necessarily evidence-based) concerns about its potential to cause thrombogenic complications, and the safest and most effective route of TXA administration remains an open question.
In this study, the IV group received TXA once before tourniquet inflation and again 3 hours later, along with a topical placebo given 5 minutes before tourniquet release. The topical group received an IV placebo at the same time intervals as the IV group, along with TXA delivered topically in the wound prior to tourniquet release. The authors found lower systemic levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis) in both groups 1 hour after tourniquet release, but PAP levels remained significantly lower in the IV group (indicating higher antifibrinolytic activity) 4 hours after tourniquet release, which was likely related to the second IV dose of TXA.
The authors also found no between-group difference in systemic or wound levels of prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), indicating there was no increase in thrombogenicity in the IV group. Interestingly, Jules-Elysee also found that the IV group had significantly higher hemoglobin and hematocrit levels 1 and 2 days after surgery, and those patients had a significantly shorter hospital stay.
Finding no major between-group differences in the mechanism of action, coagulation, or fibrinolytic profile, the authors concluded that a single IV dose of TXA may be the most simple protocol for hospitals to adopt if they are still concerned about TXA safety. Perhaps these Level-I findings will help some of the late adopters get over their fears about the safety of IV TXA.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Resection of long-bone tumors often leaves large skeletal defects. Since the late 1980s, surgeons have used the “hybrid” Capanna technique—a vascularized fibular graft inlaid in a massive bone allograft—to fill those voids, with good functional outcomes reported. In the November 20, 2019 issue of The Journal of Bone & Joint Surgery, Li et al. report on factors influencing union after the Capanna technique.
The authors radiographically evaluated Capanna-technique reconstructions in 60 patients (10 humeral, 33 femoral, and 17 tibial) and correlated allograft-host union time to the following variables:
- Patient age
- Tumor site
- Adjuvant treatment (e.g., chemotherapy)
- Previous surgical procedures
- Defect length
- Fixation method
- Fibular viability (assessed with a bone scan 10 days after reconstruction)
They also histologically analyzed a retrieved specimen from one patient.
Among these 60 reconstructions, the mean defect length was 16 cm, and the mean time to union of the constructs was 13 months. The overall survival rate of the constructs was 93% at the latest follow-up.
Multivariate linear regression revealed no correlation between allograft-host osseous union time and patient age, defect length, tumor site, or fixation method. Conversely, devitalization of the transplanted fibular graft, chemotherapy administration, and a previous surgical procedure were associated with a prolonged union time. Histologically, the allograft-host cortical junction was united by callus from periosteum of both the host bone and the fibular graft.
Li et al. conclude that “ensuring patent vascular anastomoses of the transplanted fibula is crucial to prevent delayed or nonunion.” They also suggest that Capanna-technique patients who have any of the 3 “adverse factors” noted above should be treated with extended postoperative immobilization and delayed weight-bearing.
Designing studies to answer questions about surgical procedures takes a lot of thought, effort, and experience. Creating robust study designs to investigate pain management related to musculoskeletal conditions and procedures presents additional, unique challenges.
On November 19, 2019, more than 30 orthopaedic researchers and journal editors convened to identify—and propose solutions for—those challenges. The one-of-a-kind Pain Management Research Symposium was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS award number 1R13AR076879-01) and hosted by The Journal of Bone & Joint Surgery.
Several themes emerged from the daylong discussions and presentations:
- Despite the fact that 80% of opioid prescriptions worldwide originate in the US, outcome measures going forward should focus on effective pain management rather than reduced or “zero” opioids.
- The wide variability of definitions of key research terms such as “opioid naïve” and “persistent opioid use” makes it difficult to reach robust conclusions from prior opioid/pain management research.
- Beware false equations/assumptions. For example, opioid prescription filling is not the same as opioid consumption, and persistent opioid use after surgery does not equal iatrogenic opioid dependence.
- Surgeons and other physicians must maintain a biopsychosocial perspective on pain management. Risk factors for persistent use of opioids include mental/emotional states such as depression and catastrophizing.
- Despite some equivocal reports in the orthopaedic literature, there is no convincing evidence that NSAIDs negatively affect fracture healing. Therefore, absent specific patient contraindications, NSAIDs can be considered for pain management in trauma cases.
Many more details from the Pain Management Research Symposium will appear in a special JBJS supplement, scheduled for publication in the first half of 2020.
The Journal would again like to thank all the participants for their time and energy and NIAMS for its support.
Innovation in medicine has brought innumerable improvements in patient care. For example, as late as the Vietnam War era, femoral shaft fractures were frequently treated with prolonged periods of traction—until intramedullary rods gained popularity because they helped patients mobilize soon after the injury. Similarly, negative-pressure wound therapy (NPWT) gained popularity in the 1990s because it was so helpful with treating open wounds in orthopaedics. NPWT has been a mainstay in the treatment of Wounded Warriors with blast injuries during the last 18 years of conflicts in Afghanistan, Iraq, and other war zones. But medical innovations such as NPWT often come with a high cost, which has made access to commercial NPWT unfeasible in many low-income, resource-challenged countries. Sadly, those places are also home to many patients who sustain devastating soft-tissue injuries.
In the November 20, 2019 issue of JBJS, Cocjin et al. from the Philippines report results from a randomized controlled trial that compared 7-day outcomes from a commercially available NPWT system to those from an innovative, low-cost system that the authors developed locally and have been using at their institution since the mid-2000s. This home-grown system consists of an aquarium pump converted into a reusable vacuum source, along with basic hospital supplies such as surgical gauze, tubing, and plastic food wrap. The authors also compared the cost of the two systems.
For most of the measured clinical outcomes, Cocjin et al. found that their innovative NPWT system was noninferior to the commercially available system. It was actually better (but not significantly so) in terms of time of application, pain during dressing changes, and wound-contraction percentages. There were no complications with either system, and the system made from the aquarium pump and hospital supplies cost 7 times less than the commercial device ($63.75 compared to $491.38 USD). The converted aquarium-pump system can be used up to 20 times, making its per-use cost as low as $3.
Innovation is vital to advancing orthopaedics. But we must also remember that low-cost innovation is equally important for a large portion of the worldwide patient and provider population that is resource-constrained. I applaud Cocjin et al. for sharing their locally developed innovation with the wider orthopaedic community. Although further validating studies are needed, this “homemade” NPWT system has the potential to bring to a large portion of the world a cost-effective alternative to a wound-management technique that has become a mainstay in more affluent settings over the past 2 decades.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
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 all such OrthoBuzz summaries.
This month, co-author Nitin B. Jain, MD, MSPH selected the most clinically compelling findings from the 40 studies summarized in the November 20, 2019 “What’s New in Orthopaedic Rehabilitation.”
–A randomized controlled trial compared pain-related function, pain intensity, and adverse effects among 240 patients with chronic back, hip, or knee pain who were randomized to receive opioids or non-opioid medication.1 After 12 months, there were no between-group differences in pain-related function. Statistically, the pain intensity score was significantly lower in the non-opioid group, although the difference is probably not clinically meaningful. Adverse events were significantly more frequent in the opioid group.
–A series of nested case-control studies found that the use of the NSAID diclofenac was associated with an increase in the risk of myocardial infarction in patients with spondyloarthritis and osteoarthritis, relative to those taking the NSAID naproxen.2
–Intra-articular injections of corticosteroids or hyaluronic acid are often used for pain relief prior to an eventual total knee arthroplasty (TKA). An analysis of insurance data found that patients who had either type of injection within three months of a TKA had a higher risk of periprosthetic joint infection (PJI) after the operation than those who had injections >3 months prior to TKA.
Partial-Thickness Rotator Cuff Tears
–A randomized controlled trial of 78 patients with a partial-thickness rotator cuff compared outcomes of those who underwent immediate arthroscopic repair with outcomes among those who delayed operative repair until completing 6 months of nonoperative treatment, which included activity modification, PT, corticosteroid injections, and NSAIDs.3 At 2 and 12 months post-repair, both groups demonstrated improved function relative to initial evaluations. At the final follow-up, there were no significant between-group differences in range of motion, VAS, Constant score, or ASES score. Ten (29.4%) of the patients in the delayed group dropped out of the study due to symptom improvement.
Stem Cell Therapy
–A systematic review that assessed 46 studies investigating stem cell therapy for articular cartilage repair4 found low mean methodology scores, indicating overall poor-quality research. Only 1 of the 46 studies was classified as excellent, prompting the authors to conclude that evidence to support the use of stem cell therapy for cartilage repair is limited by a lack of high-quality studies and heterogeneity in the cell lines studied.
- Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872-82.
- Dubreuil M, Louie-Gao Q, Peloquin CE, Choi HK, Zhang Y, Neogi T. Risk ofcmyocardial infarction with use of selected non-steroidal anti-inflammatory drugs incpatients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Aug;77(8): 1137-42. Epub 2018 Apr 19.
- Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med. 2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
- Park YB, Ha CW, Rhim JH, Lee HJ. Stem cell therapy for articular cartilage repair: review of the entity of cell populations used and the result of the clinical application of each entity. Am J Sports Med. 2018 Aug;46(10):2540-52. Epub 2017 Oct 12.
Surgical skills education in orthopaedics has changed dramatically from the “see one, do one, teach one” process of 30 years ago. These changes have come with a greater degree of supervision and formal skills assessments, and they have been aided by the visionary leadership at the Accreditation Council for Graduate Medical Education (ACGME) and our own orthopaedic Residency Review Committee. These skill-acquisition enhancements have benefited both our trainees and the patients we collectively care for.
A decade ago, we entered a new phase of skill development and enhancement with computer-based surgical simulators. With advances in software and widespread interest across North America in goal-driven learning through simulation, great progress has been made. In the November 20, 2019 issue of JBJS, Weber et al. report on the further validation of a surgical simulator focused specifically on percutaneous, fluoroscopically guided pin placement for femoral neck fractures. The simulator was developed in partnership between the AAOS and OTA.
This study sought to determine whether novice practitioners (medical students, in this case) who completed 9 training modules before using the simulator (the “trained” group) would perform the simulated pinning task better than peers who did not complete the presimulation training (the “untrained” group). It was no surprise to me that the trained group had a significantly higher overall performance score on the simulator. In addition, relative to the untrained group, the trained students also showed improved performance on 4 specific measures—3 of which were related to the angle between the placed pins.
These findings are clearly supportive of continued development of this and additional simulation environments. But at the same time, we need to move forward with improved documentation of surgical skill acquisition among orthopaedic residents and fellows. As simulator technology continues to improve, the next decade should yield even more positive results in skills acquisition than we saw in the last decade. We are clearly on the right path with the use of advanced technology for surgical skill development among orthopaedic trainees.
Marc Swiontkowski, MD
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.
To date, we have found only one documented disease-modifying intervention that slows the progression of knee osteoarthritis (OA)—weight loss.1 There are few positive findings about drugs or other therapeutic interventions that might prolong the life of the human joint. However, sprifermin, a recombinant human fibroblast growth factor that can be genetically engineered from bacteria, has been tested in a randomized proof-of-concept trial as an intra-articular injection in humans,2 with modestly promising results.
In a very recent study on the effect of sprifermin and several other potentially disease-modifying compounds on bovine chondrocytes, researchers used 3D cultures to assess chondrocyte proliferation and/or extracellular matrix production.3 All of the growth factors evaluated, including sprifermin, resulted in elevated markers of anabolic chondrocyte activity. For the most part, cyclic doses were more effective than continuous doses over 4 weeks. Of importance, only sprifermin decreased type I collagen expression and had no hypertrophic effects. The authors conclude in the abstract that “these results confirm that sprifermin is a promising disease-modifying OA drug.”
In a 5-year randomized human dose-finding trial,4 patients with symptomatic knee OA were divided into 5 groups, as follows:
- 100 μg of sprifermin administered every 6 months (n = 110)
- 100 μg of sprifermin administered every 12 months (n = 110)
- 30 μg of sprifermin administered every 6 months (n = 111)
- 30 μg of sprifermin administered every 12 months (n = 110)
- Placebo injections administered every 6 months (n = 108)
The greatest changes in the primary endpoint—increased total femorotibial joint cartilage thickness from baseline to 2 years—was 0.05 mm (95% CI, 0.03 to 0.07 mm) in the group that received 100 μg of sprifermin every 6 months and 0.04 mm (95% CI, 0.02 to 0.06 mm) in the group that received 100 μg of sprifermin every 12 months. However, compared with the placebo group, those receiving sprifermin had no statistically different change in WOMAC scores. On average, 40% of all the patients in the study experienced arthralgia associated with the injections.
More certainty about the efficacy, safety, and durability of sprifermin may come when data from the remaining 3 years of this study are analyzed (see ClinicalTrials.gov identifier NCT01919164).
- Gersing AS, Solka M, Joseph GB, Schwaiger BJ, Heilmeier U, Feuerriegel G, Nevitt MC, McCulloch CE, Link TM. Progression of cartilage degeneration and clinical symptoms in obese and overweight individuals is dependent on the amount of weight loss: 48-month data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2016 Jul;24(7):1126-34. doi: 10.1016/j.joca.2016.01.984. PMID: 26828356 PMCID: PMC4907808.
- Lohmander LS, Hellot S, Dreher D, et al. 2014. Intraarticular sprifermin (recombinant human fibroblast growth factor 18) in knee osteoarthritis: a randomized, double-blind, placebo-controlled trial. Arthritis Rheumatol. 66(7):1820–31.
- Müller S, Lindemann S, Gigout A. Effects of sprifermin, IGF1, IGF2, BMP7 or CNP on bovine chondrocytes in monolayer and 3D culture. J Orthop Res. 2019 Oct 14. doi: 10.1002/jor.24491. [Epub ahead of print] PMID: 31608492.
- Hochberg MC, Guermazi A, Guehring H, Aydemir A, Wax S, Fleuranceau-Morel P, Bihlet AR, Byrjalsen I, Andersen JR, Eckstein F. Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With OsteoarthritisThe FORWARD Randomized Clinical Trial. JAMA. 2019;322(14):1360-1370. doi:10.1001/jama.2019.14735
According to the orthopaedic literature, the risk of vascular injury during internal fixation of a proximal femoral fracture is low. But applying the findings from an anatomical analysis by Jaipurwala et al. in the November 6, 2019 issue of The Journal of Bone & Joint Surgery could help minimize that risk even further.
The authors examined lower-limb CT angiograms of 47 patients (mean age 69) who had the scans performed for reasons other than a femoral fracture. They then measured the distance from the tip of the greater trochanter to the profunda femoris artery and its perforators within 5 mm of the medial femoral shaft, along the length of typical placement of dynamic hip screws used for fixation of proximal femoral fractures. (The authors assumed the use of a 4-hole, 78 mm plate or a 6-hole, 110 mm plate.)
All 47 patients had 2 vessels within 5 mm of the medial femoral shaft along the line of presumed dynamic hip screw insertion. Noting that these vessels could be damaged by reduction instruments or during drilling and plate-screw insertion during actual cases of femoral-fracture fixation, Jaipurwala et al. make the following suggestions:
- Avoid or take special care when drilling or inserting screws along the femoral shaft from 110 to 120 mm from the tip of the greater trochanter in women and from 120 to 130 mm in men.
- If possible, avoid inserting a screw in the fourth hole of a 4-hole dynamic hip screw plate or inserting a screw in the fourth and fifth holes of a 6-hole plate.
The authors emphasize that these suggestions are based on measurements taken from patients who did not have a hip fracture and that “a femoral fracture may potentially alter local anatomy because of swelling and damage to surrounding structures.” But they conclude that the risk of vascular injuries in patients with a proximal femoral fracture would be further reduced if surgeons took these findings into account during operative planning and execution of hip-fracture fixation.
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Paul E. Matuszewski, MD.
A recent issue of The New England Journal of Medicine published the results from a large, multicenter randomized trial comparing the outcomes of hemiarthroplasty versus total hip arthroplasty (THA) to treat displaced femoral neck fractures in ambulatory adults.
The HEALTH investigators enrolled 1,495 patients in the study, and 85.1% of those patients had complete data for analysis after 2 years. The researchers found no significant differences between the groups with regard to the primary outcome—secondary hip procedures (7.9% in the THA group vs 8.3% in the hemi group). The risk of secondary hip procedures during the first year was higher in the THA group, but the hemiarthroplasty group had a higher risk of secondary procedures in the second year. Open/closed reductions of hip dislocations were the most common secondary procedures among the THA group, and revision to THA was the most common secondary procedure in the hemiarthroplasty group. The THA group had slightly better WOMAC scores, but the difference was not within a clinically significant range. There were no between-group differences noted in other patient-reported outcomes.
The HEALTH investigators followed these patients for only two years, which is notably the standard for many orthopaedic studies, but this short follow-up limits the practical application of these findings. The authors note that after the first year, primary THA was favorable with regard to secondary hip procedures. It is reasonable to think that this difference may become more compelling beyond 2 years, as more patients who received hemiarthroplasty are likely to be converted to THA.
The suggestion that there may not be an early benefit of THA over hemiarthroplasty in the ambulatory adult with a displaced femoral neck fracture contrasts with current recommendations from the American Academy of Orthopaedic Surgeons. However, the 2-year follow-up of this trial represents only a “snapshot” of the continuum of outcomes from these two hip-fracture treatments. The findings may add to our understanding of what our patients can expect during the first 2 years following these procedures, but I would caution surgeons against making any drastic changes to their current practice in response to this data.
Paul E. Matuszewski, MD is the Director of Orthopaedic Trauma Research and Assistant Professor of Orthopaedic Traumatology at the University of Kentucky.