Patients with diabetes have an increased risk of postoperative complications following total joint arthroplasty (TJA). Additionally, perioperative hyperglycemia has been identified as a common and independent risk factor for periprosthetic joint infection, even among patients without diabetes. Therefore, knowing a patient’s glycemic status prior to surgery is very helpful.
In the November 15, 2017 edition of The Journal of Bone & Joint Surgery, Shohat et al. demonstrate that serum fructosamine, a measure of glycemic control obtainable via a simple and inexpensive blood test, is a good predictor of adverse outcomes among TJA patients—whether or not they have diabetes.
Researchers screened 829 patients undergoing TJA for serum fructosamine and HbA1c—a common measure, levels of which <7% are typically considered good glycemic control. Patients with fructosamine levels ≥292 µmol/L had a significantly higher risk of postoperative deep infection, readmission, and reoperation, while HbA1c levels ≥7% showed no significant correlations with any of those three adverse outcomes. Among the 51 patients who had fructosamine levels ≥292 µmol/L, 39% did not have HbA1c levels ≥7%, and 35% did not have diabetes.
In addition to being more predictive of postsurgical complications than HbA1c, fructosamine is also a more practical measurement. A high HbA1c level during preop screening could mean postponing surgery for 2 to 3 months, while the patient waits to see whether HbA1c levels come down. Fructosamine levels, on the other hand, change within 14 to 21 days, so patients could be reassessed for glycemic control after only 2 or 3 weeks.
While conceding that the ≥292 µmol/L threshold for fructosamine suggested in this study should not be etched in stone, the authors conclude that “fructosamine could serve as the screening marker of choice” for presurgical glycemic assessment. However, because the study did not examine whether correcting fructosamine levels leads to reduced postoperative complications, a prospective clinical trial to answer that question is needed.
In the November 15, 2017 issue of The Journal, Courtney et al. carefully evaluate CMS data to compare TKA and THA costs, complications, and patient satisfaction between physician-owned and non-physician-owned hospitals. The authors used risk-adjusted data when comparing complication scores between the two hospital types, in an attempt to address the oft-rendered claim that surgeons at physician-owned facilities “cherry pick” the healthiest patients and operate on the highest-risk patients in non-physician-owned facilities.
In general, the findings suggest that, for TKA and THA, physician-owned hospitals are associated with lower costs to Medicare, fewer complications and readmissions, and superior patient-satisfaction scores compared with non-physician-owned hospitals. These findings should come as no surprise to readers of The Journal. One fundamental principle of health care finance is that physicians control 70% to 80% of the total cost of care with their direct decisions. When physician incentives are aligned with those related to the facility, the result is better care at lower cost.
Nevertheless, many policymakers remain convinced that physician-owners are completely mercenary and base every decision on maximizing profit margins—even if that includes ordering unnecessary tests, performing unnecessary procedures, or using inferior implants. We need more transparency among physician-owners at local and national levels to address these usually-erroneous assumptions, which are frequently repeated by local non-physician-owned health systems. For example, we should be transparent with the percentage of the margin that ends up in the physician-owner’s pocket. Whatever the “right” percentage is, I believe it should not be the dominant factor in a physician’s total income..
The findings from Courtney et al. should spur further debate on this issue. I am confident that the best outcomes for individual patients and the public result when physicians (and their patients) stay in direct control of decision making regarding care, when surgeons are appropriately motivated to be cost- and outcome-effective, and when we all do our part to care for the under- and uninsured.
Marc Swiontkowski, MD
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, Aaron Chamberlain, MD, co-author of the October 18, 2017 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.
Reverse Shoulder Arthroplasty
With reverse shoulder arthroplasty, surgeons often have difficulty setting expectations for patients due to the lack of long-term outcomes data. Bacle et al. published a study that describes the clinical outcomes in patients with at least 10 years’ follow-up. Medium-term outcomes among an original cohort of 186 patients had been previously described. Eighty-four of those original patients were available for a mean long-term follow-up of 150 months. The mean overall Constant score fell from 63 at medium-term follow-up to 55 at final follow-up. Active anterior elevation also decreased from 138° to 131.° Despite the decrease in Constant score and ROM between mid- and long-term follow-up, these two measures remained significantly better than preoperative values. Analysis showed a 93% implant survival probability at 120 months. This study will help surgeons counsel patients regarding long-term expectations after reverse shoulder arthroplasty – especially as younger patients are increasingly indicated for this procedure.
Rotator Cuff Repair
A central focus of studies evaluating rotator cuff repair has been to better understand the biological environment that influences tendon healing. Greater understanding of the genetic influence in rotator cuff pathology may lead to interventions that could improve the healing environment. Tashjian et al. reported outcomes after arthroscopic rotator cuff repair in 72 patients who were assessed for family history of rotator cuff tears and underwent a genetic analysis looking for variants in the estrogen-related receptor beta (ESRRB) gene.1 Positive family history and tear retraction were associated with a failure of healing, and lateral tendon retears were associated with both family history and the presence of a single nucleotide polymorphism in the ESRRB gene.
In another recent study focused on the biological healing environment after rotator cuff repair, a prospective randomized trial of platelet-rich plasma (PRP) in patients undergoing repair of a medium to large-sized rotator cuff tear2 found that patients who received PRP experienced an increase in vascularity at the repair site up to 3 months postoperatively. The PRP group also demonstrated better Constant-Murley and UCLA scores and lower retear rates than the no-PRP group, but there was no difference in ASES scores. In another recent randomized trial, 120 patients were randomized to either PRP or ropivacaine injection after rotator cuff repair.3 No between-group differences in clinical outcome scores or retear rates were identified. The contrasting results of these two recent randomized studies illustrate the challenge of identifying any conclusive benefit of PRP in the setting of rotator cuff repair.
Prosthetic Shoulder Infection
Accurate diagnosis of prosthetic shoulder infection continues to present a formidable challenge, given the difficulty of detecting Proprionibacterium acnes (P. acnes) and interpreting when positive results are clinically significant. Development of P. acnes tests that are more rapid and precise in identifying clinically significant infections would be of significant value. Holmes et al. evaluated a PCR restriction fragment length polymorphism (RFLP) technique to identify P. acnes from infected tissue in the shoulder.4 In this study, within 24 hours of sampling, the PCR-RFLP assay detected P. acnes-specific amplicons in as few as 10 bacterial cells.
Approaches to managing clavicle fractures have evolved significantly over the past several decades. While it was once generally accepted that middle third clavicle fractures should be managed nonoperatively, multiple studies have described concerning rates of nonunions and symptomatic malunions. A multicenter prospective trial that randomized patients to either surgical fixation with a plate or nonoperative management identified a nonunion rate of 23.1% in the nonoperatively managed group, compared with a 2.4% nonunion rate in the surgically treated group (p<0.0001). However, the rate of secondary operations was 27.4% in the operatively treated group (most for plate removal) versus 17.1% in the nonoperative group, although that difference did not reach statistical significance (p=0.18). These results will help inform discussions between providers and patients when considering management options for midshaft clavicle fractures.
- Tashjian RZ, Granger EK, Zhang Y, Teerlink CC, Cannon-Albright LA. Identification of a genetic variant associated with rotator cuff repair healing. J Shoulder Elb Surg. 2016. doi:10.1016/j.jse.2016.02.019.
- Pandey V, Bandi A, Madi S, et al. Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial. J Shoulder Elb Surg. 2016;26(3):e82-e83. doi:10.1016/j.jse.2016.01.036.
- Flury M, Rickenbacher D, Schwyzer H-K, et al. Does Pure Platelet-Rich Plasma Affect Postoperative Clinical Outcomes After Arthroscopic Rotator Cuff Repair? Am J Sports Med. 2016. doi:10.1177/0363546516645518.
- Holmes S, Pena Diaz AM, Athwal GS, Faber KJ, O’Gorman DB. Neer Award 2017: A rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder. J Shoulder Elb Surg. 2017. doi:10.1016/j.jse.2016.10.001.
Launched in July 2011 and co-edited by Thomas W. Bauer, MD and Ronald W. Lindsey, MD, JBJS Case Connector compiles thousands of orthopaedic case reports, empowering surgeons to find cases similar to theirs, to identify emerging trends, and to distinguish between truly rare cases and repeated, related instances of a larger problem. Using this unique online journal, surgeons can find the commonalities between cases and filter case information by many important variables to provide the best possible care for orthopaedic patients.
In addition, monthly “Case Connections” essays explore the clinical relationships between recent articles and prior case reports in the wider orthopaedic literature, helping surgeons to identify potential patterns. And JBJS Case Connector “Image Quizzes” provide interactive challenges based on JBJS case-report images, featuring in-depth discussions of relevant ideas and concepts.
If you are not already a JBJS Case Connector subscriber, click here to learn more.
This basic science tip 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.
One clinical frustration following osteomyelitis debridement is poor bone healing. Impaired bone homeostasis provokes serious variations in bone remodeling that involve multiple inflammatory cytokines.
The chemokines CCL2, CCL3, and CXCL2 are known to be strong chemoattractants for neutrophils during inﬂammatory states, and they play a role during osteoclastogenesis. B cells are also activators of osteoclastognesis and are regulated, in part, by tissue inhibitor of metalloprotease 1 (TIMP-1).
Researchers drilled a 1 mm hole into the proximal tibia of 126 mice. In half of the mice (63), a dose of S. aureus was injected into the canal, while the controls had no bacteria injected. At two weeks, all proximal tibiae were debrided; cultures were taken 3 and 7 days after debridement to assure no residual infection. Cytokine assays and Western blots for CCL2, CCL3, CXCL2, TIMP-1, RANKL, and TNF-α were performed in selected mice in each group. Flow cytometry and histology were also done in selected mice in each group.
In the osteomyelitis group, Western blot analysis identified increased levels of CCL2, CCL3, and CXCL2. Histology revealed increased osteoclastogenesis after osteomyelitis debridement, with calcitonin-receptor and RANKL detection via immunohistochemical and fluorescence staining. There was diminished osteogenesis and proliferation in the osteomyelitis group, but TNF-α expression seemed to have no effect on altered bone regeneration after bone infection. Flow cytometry revealed elevated B cell activity in the osteomyelitis group, with subsequent increased osteoclast activity and accelerated bone resorption.
The researchers propose a RANKL-dependent osteoclastogenesis after debridement for osteomyelitis that is associated with elevated B cells and decreased osteogenesis. These findings could lead to new interventions to improve bone healing during the course of osteomyelitis treatment, particularly following debridement.
Wagner JM, Jaurich H, Wallner C, Abraham S, Becerikli M, Dadras M, Harati K, Duhan V, Khairnar V, Lehnhardt M, Behr B. Diminished bone regeneration after debridement of posttraumatic osteomyelitis is accompanied by altered cytokine levels, elevated B cell activity, and increased osteoclast activity. J Orthop Res. 2017 Mar 6. doi: 10.1002/jor.23555. [Epub ahead of print] PMID: 28263017
The relationship between chronic kidney disease (CKD) and acute kidney injury (AKI) is circular: surgical patients with preexisting CKD are at increased risk of AKI, and even mild or transient AKI is associated with future development of CKD.
In the November 1, 2017 JBJS, Gharaibeh et al. report findings from a retrospective cohort study with a nested case-control analysis that assessed the rate and risk factors associated with AKI after total hip arthroplasty (THA).
From a total of 10,323 THAs analyzed, AKI developed postoperatively in only 114 cases (1.1%). A multivariate analysis of the entire cohort identified four preoperative comorbidities that increased the risk of AKI by 2- to 4-fold: CKD, heart failure, diabetes, and hypertension. In addition to those risk factors, an analysis of the case-control cohort found that increasing BMI and perioperative blood transfusions were also associated with a higher risk of AKI.
Using data from the entire cohort, the authors developed an AKI risk calculator focused on presurgical variables (see graph). Based on that model, which will require independent validation, a 65-year-old man with either CKD or heart failure would have a 2% risk of AKI; the risk would increase to 4% if that patient had CKD and hypertension and to 16.1% in the presence of CKD, hypertension, and heart failure.
The anticipated increase in demand for joint replacements could lead to US surgeons performing approximately 572,000 THAs during the year 2030. A certain (and possibly increasing) proportion of those future procedures will occur in patients who have hypertension, diabetes, heart failure, and/or chronic kidney disease. The findings from Gharaibeh et al., especially the yet-to-be-validated AKI risk score, could help hip surgeons better counsel patients and identify those who might benefit from heightened postsurgical monitoring of kidney function.
On November 15, 2017 at 7 PM EDT, JBJS will join with JSES (Journal of Shoulder and Elbow Surgery) to present a webinar looking at the current paradigm for treating clavicle fractures. Co-moderated by Drs. William Mallon, editor-in-chief of JSES, and Andrew Green, deputy editor of JBJS, the webinar will focus on two recent clavicle-fracture papers:
- Dr. Philip Ahrens will discuss his recent JBJS paper, “The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures.”
- Dr. Brian Feeley will discuss his 2016 JSES paper, “Plate Fixation of Midshaft Clavicular Fractures: Patient-Reported Outcomes and Hardware-Related Complications.”
After each author presentation, expert commentary will be provided. Discussing Dr. Ahrens’ paper will be Dr. Michael McKee, recently named chairman of orthopaedics at the University of Arizona. Dr. Gus Mazzocca, chairman of orthopaedics at the University of Connecticut, will comment on Dr. Feeley’s paper. The webinar will then be open to addressing viewer-submitted questions for the authors and the commentators.
Seats are limited, so register now!
An authoritative source for clinically useful orthopaedic information for more than 125 years, The Journal of Bone & Joint Surgery (JBJS) has launched an entirely reengineered website—jbjs.org. This superior online orthopaedic experience—fully optimized for mobile devices—speeds users to targeted content across all six JBJS journals. With a more robust search engine and subspecialty collections, the new jbjs.org delivers practice-specific research results for journal articles, videos, images, webinars, podcasts, and CME activities—all with a single click.
Complimentary access to the new jbjs.org is available until December 31, 2017.
The new website also enhances the capacity of “My JBJS,” where users can store and organize content they have bookmarked. In addition, the site offers clearly organized direct links to JBJS CME material that is related to the user’s search query.
The new jbjs.org also features Clinical Summaries, 300- to 400-word “mini-reviews” of the latest clinical findings pertaining to 100 of the most common orthopaedic conditions. Each Clinical Summary is accompanied by direct links to the most relevant, highly cited articles in JBJS and other peer-reviewed orthopaedic and general-medicine journals. “We believe that Clinical Summaries represent a uniquely useful and evidence-based contribution to orthopaedic practice and the review process in orthopaedic surgery—and that they will improve patient care and enhance professional satisfaction,” said JBJS Editor-in-Chief Marc Swiontkowski, MD.
“The new jbjs.org gives us a unique publishing platform that allows the physician to control the experience,” said Paul Sandford, Chief Executive Officer at JBJS. “All digital content resources—including articles, videos, images, and more—can now be easily located and utilized through a proprietary search feature, subspecialty collections, and Clinical Summaries. This application will open the door for new developments and expand our presence and impact with orthopaedists both in the US and globally.”
For more information about the entirely new jbjs.org, click here.
Although the indications for anatomic and reverse total shoulder arthroplasty (TSA) are different, better understanding of the rate of improvement with each type of surgery could help establish more realistic patient expectations for recovery—and help surgeons and physical therapists design different strategies for postoperative care. With those goals in mind, Simovitch et al. use prospectively collected data to compare, at a minimum 2-year follow-up, clinical and range-of-motion (ROM) outcomes among 505 anatomic TSA patients and 678 reverse TSA patients. The findings appear in in the November 1, 2017 issue of JBJS.
The authors tracked five clinical outcome scores (SST, UCLA Shoulder, ASES, Constant, and SPADI), along with 4 relevant ROM measures. In both groups, >95% of patients reported clinical improvement in all 5 clinical metrics by 6 months, and full improvement was noted by 24 months. Not surprisingly, the mean age of patients who underwent reverse TSA was >5 years older and their shoulder-function scores and ROM were generally worse than those of the anatomic TSA patients.
At the time of the latest follow-up, patients who underwent anatomic TSA fared significantly better than patients who underwent reverse TSA in 3 of the 5 clinical outcome metrics and in all 4 ROM measurements. On the other hand, those who had reverse TSAs had significantly larger improvements in the Constant score (which emphasizes strength more than the other 4 clinical metrics) and active forward flexion.
ROM-wise, at approximately 6 years after surgery, the authors noted a progressive decrease in the magnitude of improvement for abduction and forward flexion in both groups. According to Simovitch et al., the observed discrepancies between clinical and ROM outcomes at longer-term follow-up suggest that “subjective (e.g., patient-reported) assessments of outcome and function likely continue to be stable or improve despite range-of-motion worsening and, as such, may imply that patient expectations change with follow-up time.”
Basic science investigations into clinically relevant orthopaedic conditions are very common—and often very fruitful. What’s not very common is seeing results from large, multicenter randomized trials published in the same time frame as high-quality in vivo basic-science research on the same clinical topic.
But the uncommon has occurred. In the November 1, 2017 issue of The Journal, Chiaramonti et al. present research on the effects of 20-psi pulsatile lavage versus 1-psi bulb-syringe irrigation on soft tissue in a rat model of blast injuries. With support from the US Department of Defense, Chiaramonti et al. developed an elegant animal study that found radiological and histological evidence that lavage under pressure—previously thought to be critical to removing contamination in high-energy open fractures—results in muscle necrosis and wound complications.
Although none of the rats developed heterotopic ossification during the 6-month study period, the authors plausibly suggest that the muscle injury and dystrophic calcification they revealed “may potentiate the formation of heterotopic ossification by creating a favorable local environment.” Heterotopic ossification is an unfortunately common sequela in patients who suffer blast-related limb amputations.
The aforementioned rare alignment between basic-research findings and clinical findings in people relates to a large multicenter randomized clinical trial recently published in The New England Journal of Medicine. That study found that one-year reoperation rates among nearly 2,500 patients treated surgically for open-fracture wounds were similar whether high, low, or very low irrigation pressures were used. This is a case where the clinical advice from basic-study authors Chiaramonti et al. to keep “delivery device irrigation pressure below the 15 to 20-psi range” when managing open fractures is based on very solid ground.
Marc Swiontkowski, MD