Video Summary: Diagnostic Utility of a Point-of-Care Test of Calprotectin for PJI After TKA

A new JBJS video summary is available now. View the video below, and read the full article here.

Isoelastic Monoblock vs Modular Press-Fit Cup 

As the volume of total hip arthroplasty (THA) cases continues to rise, so too will the need for revision surgery. Revision THA can be complicated by insufficient bone stock on either the femoral or acetabular side, and researchers are gaining further insight into bone loss potentially related to implant design, such as loss that may occur through stress-shielding from press-fit implants.  

 In a randomized controlled trial recently reported in JBJS, Brodt et al. evaluated reduction in bone mineral density (BMD), primarily periacetabular BMD, as measured in 2 groups: patients who received a press-fit isoelastic monoblock cup (24 patients analyzed) and those who received a modular titanium press-fit cup (23 patients analyzed). At question was whether an isoelastic monoblock cup, with an elastic modulus similar to that of bone, would lead to less stress-shielding and thus less bone loss compared with a conventional modular titanium cup. 

Periprosthetic BMD was assessed at 1 week postoperatively (baseline) and at 4 years postoperatively using dual x-ray absorptiometry (DXA). The authors evaluated 4 regions of interest (ROIs) around the acetabular component and 7 ROIs around the femoral component based on regions previously described in the literature for assessing periprosthetic bone loss. 

Baseline patient characteristics, operative time, and improvement in clinical outcome scores did not differ between the groups.  A decrease in overall periacetabular BMD was found in both groups, but the difference between the groups was not significant. 

However, the researchers found a significant difference between the groups in BMD changes in certain periprosthetic regions. On the acetabular side, the group with the modular titanium cup had a 15.9% decrease in BMD in zone 2 (the superior pole of the acetabulum) compared with a decrease of 4.9% in the group with the isoelastic monoblock cup. And on the femoral side, the group with the modular titanium cup had a 15.4% decrease in BMD in zone 1 (along the greater trochanter) compared with a loss of 7% in the group with the isoelastic monoblock cup. None of the other regions differed significantly between the groups.   

Despite the relatively short follow-up and small (but adequately powered) numbers, these results are worthy of our consideration. I agree with the authors that longer follow-up is needed before conclusions can be drawn. As implant design can impact component longevity, it is critical that we evaluate differences to better understand the long-term implications. 

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

 

JBJS Webinar June 28–Femoral Neck Fractures: The THA vs Hemi Toss-Up

Consulting with their patients, orthopaedic surgeons make many decisions each day by weighing the best evidence available. One frequent—and controversial—decision is how best to treat displaced femoral neck fractures, a common injury among elderly patients.

Often this choice comes down to hemiarthroplasty (HA) or total hip arthroplasty (THA). The preponderance of evidence suggests that outcomes from both procedures are nearly equivalent. On Monday, June 28, 2021 at 8 pm EDT, JBJS will host a complimentary 1-hour webinar delving into the most recent findings about this dilemma. 

Mohit Bhandari, MD, PhD will present findings from a 2020 Level-I meta-analysis of 16 randomized controlled trials. Functional outcomes and 5-year rates of revision and dislocation were similar between groups. THA eked out a small advantage in health-related quality of life, and HA yielded minor reductions in operative time.

Bheeshma Ravi, MD, PhD will discuss data comparing the 2 procedures in terms of complications and costs. Based on findings from this propensity score-matched analysis, the nod goes to THA, with lower 1-year rates of revision surgery and lower health-care costs. 

Moderated by Bassam A. Masri, MD, FRCSC, the webinar will feature expert commentaries on these “neck-and-neck” findings. Pierre Guy, MD will comment on Dr. Bhandari’s paper, and Kelly Lefaivre, MD will weigh in on Dr. Ravi’s paper. 

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists. 

Seats are limited–so Register Today!  

CME credit will be available for surgeons and PAs attending this event live for a minimum of 50 minutes. Directions to claim your CME credit will be sent out within 48 hours of the broadcast. 

Journal Club Resident Spotlight: Jacob Wilson

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The grant program promotes career-long skills in evaluating the orthopaedic literature. Click here for more information.

Name: Jacob Wilson, MD

Affiliation: Emory University School of Medicine, Atlanta

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

We recently held an arthroplasty-themed journal club that was well received. We discussed 4 different papers, but I found the discussion on 2 to be particularly interesting. This included a study on long-term outcomes of cemented versus cementless total knee arthroplasty[1] and a randomized controlled trial on the use of virtual physical therapy visits after total knee arthroplasty.[2] These studies were well-designed and stimulated lively discussion.

  1. Kim, Y.H., J.W. Park, and Y.S. Jang, The 22 to 25-Year Survival of Cemented and Cementless Total Knee Arthroplasty in Young Patients. J Arthroplasty, 2021. 36(2): p. 566-572.
  2. Prvu Bettger, J., et al., Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial. J Bone Joint Surg Am, 2020. 102(2): p. 101-109.

What are the top 3 characteristics of an engaging, enlightening journal club presentation?

In my experience, journal club can be one of the better educational opportunities as a resident. There are a few things that are critical to making this the case. 1) Obviously, everyone needs to read the articles that are being discussed. This goes a long way in making the journal club interactive and constructive. 2) Attendance, particularly by faculty, is critical. I have found that when faculty from a variety of subspecialties attend, good discussions are generated. 3) Proper article selection. While landmark papers are important and should be reviewed by all residents, for the purposes of journal club, recent, clinically applicable articles that have the potential to change practice seem to be more interesting to those in attendance.

How has the COVID-19 pandemic affected your journal-club activities?

Like essentially all aspects of our lives, COVID-19 significantly changed our journal-club activities over the past year. Given national, regional, and institutional guidelines, our program moved all educational activities, including journal club, to virtual formats. While different than what we were previously accustomed to, this has made attendance easier for some faculty. That said, we are looking forward to a return to some degree of academic normalcy when we are able.

Aside from orthopaedic content, what have you been reading lately?

I’ve admittedly slacked on reading outside of orthopedics during residency. However, I have always been a fan of narrative nonfiction and am currently reading Dead Wake by Erik Larson.

How has free access to JBJS Clinical Classroom benefited you and your journal club?

I have found JBJS Clinical Classroom to be a good resource. As I prepare for Part I of my board exam, Clinical Classroom has been an easy and nice way to review concepts quickly. The app has made it easy to quickly do a few questions between cases. The content in Clinical Classroom is linked to primary literature, and this has led to some articles being selected for discussion at journal club.

JOPA Writing Award Spotlight: Katherine Crandall 

 

The JBJS Journal of Orthopaedics for Physician Assistants (JOPA) continues the tradition of recognizing outstanding review articles and case studies submitted during the previous year by practicing PAs, NPs, and PA students. OrthoBuzz is pleased to spotlight the winners of the 2020 JBJS JOPA Writing Awards.

Name: Katherine Crandall, PA-S

Affiliation: Keck School of Medicine, University of Southern California

JOPA Article: “Physician Assistant Roles in Prevention and Management of Anterior Cruciate Ligament Injury

Tell us about your paper.

I chose to write a review article on the topic of physician assistant roles in the prevention and management of anterior cruciate ligament (ACL) injury. The roles and responsibilities of physician assistants — both in primary care and in orthopaedics — seamlessly translate to ACL care from primary prevention to long-term management.

PAs can help to prevent ACL rupture by screening for patients at risk for this injury, providing patient education on neuromuscular training techniques, and referring patients to available ACL rupture-prevention programs. Furthermore, I propose that the creation of a standardized screening tool assessing for ACL rupture risk may aid primary care PAs in screening patients for this injury.

Additionally, patients recovering from ACL ruptures can experience apprehension to return to sport, as the injury and the recovery process can be mentally traumatizing. As PAs frequently perform long-term care for patients during this process, they are well positioned to assess and intervene as needed for patients experiencing psychological obstacles throughout the process.

PAs embody the training, skills, and scope of practice to prevent and manage ACL injury; therefore, it becomes imperative to promote PA involvement in this injury.

How did you decide to write on this topic?

After working alongside physician assistants in orthopaedics both prior to PA school and throughout my clerkships, I witnessed firsthand the ability of PAs to help their orthopaedic teams meet goals in patient care. This stood true whether they were working on an orthopaedic team in the clinic, the OR, or other settings.

Additionally, while working in sports medicine and seeing patients recovering from ACL rupture, I noticed that there was overlap between the care required for this particular injury (i.e. prevention, acute care, long-term continuity of care) and the roles and responsibilities of PAs. I suspected that PAs could play a particularly instrumental role in preventing and managing this injury, and decided to investigate further.

What was the most interesting “take-away,” in your opinion?

The recovery period from an ACL rupture can be challenging both physically and psychologically. While there is ample focus placed on the physical recovery from this injury, patients frequently lack adequate psychological assessment and care during their recovery — an element of the healing process that is fundamental to an athlete’s safe return to activity.

Physician assistants are often involved in long-term care for patients recovering from ACL rupture. They have the opportunity to assess patient progression and recovery, both in the physical and psychological perspectives, and to act or intervene as needed. One way PAs can monitor their patients’ psychological progress is by using the ACL Return-to-Sport Index (ACL-RSI), which assesses a patient’s mental readiness to resume their activities. PAs regularly utilize clinical screening tools such as the PHQ-9 for depression or the CAGE questionnaire for alcohol abuse; therefore, PAs could utilize the ACL-RSI to monitor their patients’ readiness, and subsequently counsel or refer to psychological professionals as needed.

What do you enjoy most about your career?

Currently a PA student, I am scheduled to soon take (and hopefully pass!) my PA Boards. While I do not have a career yet, I can say that my greatest enjoyment as a student (outside of patient care) has been connecting with individuals and groups that are similarly passionate about the PA career, orthopaedics, and other similar health-care interests of mine such as advocacy, community involvement, and preventive medicine. I have been fortunate to participate in leadership and advocacy positions in my own USC program as well as with various PA organizations such as the Physician Assistant Education Association and the American Academy of PAs. In doing so, I have collaborated with numerous passionate and driven students, PAs, and others throughout the country, which has endured as a source of inspiration throughout my studies.

I would also like to thank Dr. Jennifer Beck for her assistance and continued support.

How do you stay informed about new developments in orthopaedics?

I keep up-to-date through JBJS, Physician Assistants in Orthopaedic Surgery, and other orthopaedic journals. I will now be sure to tune in to OrthoBuzz as well!

What are you currently reading/listening to/watching?

Listening to the Home Cooking podcast, reading The Body Keeps the Score, and watching The Crown.

More details about the JBJS JOPA Writing Awards can be found here.

 

Caution Appropriate as We Investigate New Approaches to Pain Management 

The dangers of chronic opioid use have rightly been at the forefront of orthopaedic practice considerations in recent years. The widespread use of regional anesthesia and periarticular-injection cocktails, targeted NSAID utilization, and strict limitations on opioid use have become standard approaches for postoperative pain management.  

With the availability of cannabinoids in numerous state jurisdictions, attention has now turned to the potential of these compounds to enhance patient comfort in the postoperative period. However, as we contemplate their use, it’s imperative that we also evaluate the impact of these compounds on clinically important outcomes such as  bone-healing and fusion. The track record of nicotine, NSAIDs, and other compounds in terms of the impact on bone-healing is enough to suggest caution.   

In the June 2, 2021 issue of JBJS, Yun et al. provide new insight into this topic. Specifically, they evaluated the impact of cannabinoid receptor agonist WIN55 on osteogenic differentiation in vitro and bone regeneration and spinal fusion in a preclinical rat model.  

They found that WIN55 had no adverse impact on osteogenic differentiation of primary bone marrow stem cells in vitro. As noted by the authors, “mRNA expression levels of Runx2 and Alp were similar among cells treated with vehicle alone and WIN55. Likewise, exposure to WIN55 did not inhibit ALP [Alkaline phosphatase] activity or bone matrix mineralization.”  

In addition, no adverse impact of WIN55 on spinal fusion or bone regeneration was found. Forty-five rats (15 per group) underwent L4-L5 posterolateral spinal fusion with bilateral placement of collagen scaffolds soaked with rhBMP-2. The rats were treated with vehicle alone or 0.5 or 2.5 mg/kg WIN55 by way of daily intraperitoneal injections for 5 days. Radiography, manual palpation-based fusion scoring, microCT, and histology were used for assessment. No significant differences among the groups in the mean fusion score, fusion rate, and new bone volume were demonstrated. 

These findings are intriguing, and such research helps set the stage for carefully designed in vivo research projects, eventually moving toward randomized controlled trials, before recommending widespread use of cannabinoids for post-surgical pain management. 

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

 

What’s New in Foot and Ankle Surgery 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Timothy R. Daniels, MD, FRCSC summarizes the 5 most compelling findings from the >80 studies highlighted in the recently published “What’s New in Foot and Ankle Surgery.”

Telemedicine 

–With virtual foot and ankle examinations become more widespread during the COVID-19 pandemic, a recent paper on telehealth consultations offers guidance on preparing patients for the appointment as well as examination instructions that can be read by clinicians to patients and a checklist for medical record documentation1.

Ankle Reconstruction 

–Evaluating trends in foot and ankle surgery in Germany over the past decade, 1 study found that the volume of foot and ankle operations increased 39.5%, while the population increased 0.9%2. The volume of first metatarsophalangeal joint (MTPJ) arthrodesis and ankle arthrodesis rose 77% and 31%, respectively, whereas first MTPJ arthroplasty and total ankle replacement declined 48% and 39%.

Total Ankle Replacement 

– In a prospective series of total ankle replacement procedures in which a standard anterior approach or an extensile anteromedial surgical approach was used in patients at higher risk for wound complications, 17 (2.6%) of 660 patients had major and 39 (5.9%) had minor wound-healing issues3. All major wound complications occurred in the anterior-approach group.

Morton Neuroma 

–A recent study assessed the utility of preoperative imaging and intraoperative histopathology in Morton neuroma4. Among 313 suspected neuromas operatively resected during the 10-year study period, Morton neuroma was confirmed in 309 (98.7%) on histopathologic examination. The postoperative treatment course was not altered for any patient on the basis of the pathology report, challenging the cost and utility of histopathologic evaluation of resected neuromas.

Patient-Reported Outcomes 

–Another recent study investigated the question of whether sociodemographic factors impact PROMIS scores meeting the Patient-Acceptable Symptom State (PASS) among foot and ankle patients. The authors found that patients ≥65 years of age accepted more functional limitation than younger patients, patients in the lowest income brackets reported more severe functional limitations as satisfactory compared with patients in the highest income brackets, and patients in the lowest income bracket sought surgical care later than those in the highest income bracket5.

References 

  1. Eble SK, Hansen OB, Ellis SJ, Drakos MC. The virtual foot and ankle physical examination. Foot Ankle Int. 2020 Aug;41(8):1017-26. Epub 2020 Jul 8.
  2. Milstrey A, Domnick C, Garcia P, Raschke MJ, Evers J, Ochman S. Trends in arthrodeses and total joint replacements in foot and ankle surgery in Germany during the past decade-back to the fusion? Foot Ankle Surg. 2020 May 26 [Epub ahead of print].
  3. Halai MM, Pinsker E, Daniels TR. Effect of novel anteromedial approach on wound complications following ankle arthroplasty. Foot Ankle Int. 2020 Oct;41(10):1198-205. Epub 2020 Jul 18.
  4. Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of preoperative imaging and intraoperative histopathology in Morton’s neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-6. Epub 2019 May 29.
  5. Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients? Clin Orthop Relat Res. 2019 Nov;477(11):2555-65.

“Normal” Ultrasound May Not Rule Out DDH Later in Childhood

Some years ago, we moved away from calling hip dysplasia “congenital” and started using the term “developmental dysplasia of the hip” (DDH). Indeed, it is developmental. As a surgeon specializing in pediatric orthopaedics and hip preservation, I see not only infants when DDH is of potential concern but also young adults with more mature manifestations of hip dysplasia not previously diagnosed or treated.

Screening protocols have successfully helped in the early identification of DDH and dislocation, but what is the likelihood that infants with risk factors for dysplasia but normal ultrasound results will go on to experience DDH in childhood? And which risk factors are predictive?

In a recent report in JBJS Open Access, Humphry et al. provide new insight into these challenging questions. This study from the UK included 1,053 children from a cohort of 2,191 children who had been assessed as newborns and had at least 1 of 9 perinatal risk factors for DDH. All had undergone ultrasound at a mean of 8 weeks and were followed clinically.

The mean age of the children in the current study was 4.4 years (range, 2.0 to 6.6 years). Thirty-seven of the participants had been treated for DDH in the postnatal period, predominantly with a harness.

Assessing the acetabular index (AI) on pelvic radiographs, the authors found that:

  • 27 of the children had “severe” hip dysplasia (an AI of >2 standard deviations above age and sex reference values). Girls were more likely to have this outcome. Only 3 of the 27 received treatment for DDH in infancy.
  • 146 (13.9%) of the children had an AI of >20°, only 12 of whom had been treated during infancy; 92% had no prior diagnosis of DDH. On multivariate analysis, female sex and breech presentation at birth were significantly predictive of this “mild” dysplasia (breech presentation demonstrated a nearly twofold increased odds of an AI of >20° at ≥3 years of age), while first-born status had a protective effect.

The findings of this study lend support to radiographic monitoring later in childhood for patients with risk factors such as breech positioning at birth. While the exact algorithm of ultrasound and radiographic workup still needs to be elucidated, it appears that a “normal” ultrasound in infancy does not necessarily rule out the development of hip dysplasia in children with select risk factors.

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

Multiligamentous Knee Injury May Not Be Synonymous with Knee Dislocation

Terminology is important in orthopaedics. When teaching, for instance, we stress the need for trainees to be able to articulate what a radiograph is showing using descriptive terms and classification systems.

Over the years, “multiligamentous knee injury” (MLKI) and “knee dislocation” have increasingly been used interchangeably within the orthopaedic vernacular, in part  because of the high energy required to sustain such injuries, but also because of the potentially devastating complications that can be associated with both.

Kahan et al. sought to better characterize these injuries and their associated complications in a study now reported JBJS. They retrospectively evaluated cases treated at their Level-I trauma center between 2001 and 2020.

A total of 123 patients with MLKI were included in the analysis: 45 patients with and 78 patients without a documented knee dislocation. MLKI was defined as disruption of at least 2 of the following: the anterior cruciate, posterior cruciate, medial collateral, and lateral collateral ligaments. Cruciate ligament injuries and isolated injuries of the superficial medial collateral ligament were not included unless there was disruption of the posteromedial corner, semimembranosus, or medial patellofemoral ligament, indicating a more extensive medial-sided injury.

The investigators found that medial-sided injuries were more common in the dislocation group (53% vs 30%; p = 0.009), and the dislocation group had higher rates of peroneal nerve injury (38% vs 14%; p = 0.004) and vascular injury (18% vs 4%; p = 0.018). Of the 11 total patients with a vascular injury, 8 (73%) were in the dislocation group; 10 of the 11 underwent a vascular surgical procedure.

Not all cases of MLKI are a result of a knee dislocation, and in this adequately powered study, there were differences in the injury pattern and associated injuries between those with and without true dislocation. It is important to note that, although higher rates of neurovascular injury were seen in the dislocation group, such events also occurred in the group without dislocation, so a high index of suspicion must be maintained with these complex injuries. As the authors suggest, it may be better to consider cases of knee dislocation a subset of MLKI with the potential for increased neurovascular compromise.

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