JBJS 100: Arthroscopic Supraspinatus Repair and OCD of the Talus

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Arthroscopic Repair of Full-Thickness Tears of the Supraspinatus
P Boileau, N Brassart, D J Watkinson, M. Carles, A M Hatzidakis, S G Krishnan: JBJS, 2005 June; 87 (6): 1229
This evaluation of the arthroscopic tension-band suture technique demonstrated that arthroscopic repair of an isolated supraspinatus detachment delivers good to excellent functional and tendon-healing results—and that the absence of tendon healing does not necessarily compromise pain relief and patient satisfaction.

Transchondral Fractures (Osteochondritis Dissecans) of the Talus
A L Berndt and M Harty: JBJS, 1959 Sept; 41 (6): 988
Berndt and Harty’s elegant clinical and anatomic study included a four-stage radiological classification scheme for traumatic talar lesions that still provides a valid foundation for decision-making with regard to operative or nonoperative treatment.

Excess Opioid Medication Video Summary

Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. https://goo.gl/rZaM3y 

Fixation Costs for Distal Radial Fracture

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value. https://goo.gl/mos4dc 

Excess Prescription Opioids

Postoperative management in orthopaedic surgery accounts for a substantial portion of medications prescribed in the United States. https://goo.gl/H93hya 

Fragility Fracture Risk Prediction: Beyond BMD

BMD for OBuzzThis 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.

Bone mineral density (BMD)—a measure of both cortical and trabecular bone—has been widely used as an index of bone fragility. The femoral neck and lumbar vertebrae are the areas most commonly measured with BMD, but hip osteoarthritis and lumbar spondylosis can mask systemic osteoporosis. In addition, the most common fragility fractures occur at the distal radius.

Investigators conducted a prospective study using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia to determine whether baseline skeletal parameters could predict fragility fractures in women. A second goal was to establish whether women who have fragility fractures experience bone loss at a faster rate than those who do not have fractures.

Among 149 women older than 60 years who had baseline and 5-year follow-up HR-pQCT, 22 had a fragility fracture during the study period and 127 did not. HR-pQCT is able to record total bone mineral density (Tt.BMD), trabecular bone mineral density (Tb.BMD), trabecular number (Tb.N), and trabecular separation (Tb.Sp).

The analysis showed that women with fragility fractures had lower baseline Tt.BMD (19%), Tb.BMD (25%), and Tb.N (14%), along with higher Tb.Sp (19%) than women who did not experience a fracture. Analysis of the tibia measures yielded similar results, showing that women with incident fracture had lower Tt.BMD (15%), Tb.BMD (12%), cortical thickness (14%), and cortical area (12%). Also, women with fractures had lower failure load (10%) with higher total area and trabecular area than women without fractures.

For each standard deviation decrease of a measure at the distal radius, the odds ratio for fragility fracture was 2.1 for Tt.BMD. 2.0 for Tb.BMD, and 1.7 for Tb.N. ORs for those measures at the tibia were similar.

In contrast to these findings, the annualized percent rate of bone loss was not different between groups with and without fractures. These results suggest that future fragility-fracture risk prediction should rely at least as much on bone architecture and strength as on simple BMD measurements.

Reference
Burt LA, Manske SL, Hanley DA, Boyd SK. Lower Bone Density, Impaired Microarchitecture, and Strength Predict Future Fragility Fracture in Postmenopausal Women: 5-Year Follow-up of the Calgary CaMos Cohort. J Bone Miner Res. 2018 Jan 24. doi: 10.1002/jbmr.3347 PMID: 29363165

What’s New in Adult Reconstructive Knee Surgery 2018

Knee_smEvery 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery.

Nonoperative Knee OA Treatment

—Intra-articular corticosteroid injections are commonly administered to mitigate pain and inflammation in knee osteoarthritis (OA). However, a randomized controlled trial of 140 patients found that 2 years of triamcinolone injections, when compared with saline injections, resulted in a significantly greater degree of cartilage loss without significant differences in symptoms.1

Non-Arthroplasty Operative Management

—Knee arthroscopy continues to be largely ineffective for pain relief and functional improvement in knee OA. A randomized controlled trial found no evidence that debridement of unstable chondral flaps found at the time of arthroscopic meniscectomy improves clinical outcomes.

Cartilage restoration procedures continue to show varying degrees of success. Long-term results from a randomized trial demonstrated no significant differences in joint survivorship and function between patients undergoing microfracture versus autologous chondrocyte implantation (ACI) at 15 years of follow-up. Nearly 50% of patients in both groups had radiographic evidence of early knee OA.

Periprosthetic Joint Infection

—Periprosthetic joint infection (PJI) remains a leading cause of failure following total knee arthroplasty (TKA). Successful treatment requires accurate diagnosis, and alpha-defensin was found to be both sensitive and specific in the diagnosis of PJI. However, it was not significantly superior to leukocyte esterase (LE) in cases of obvious infection.

—Reported rates of reinfection after 2-stage reimplantation for treatment of a first PJI can be as high as 19%. A 3-month course of oral antibiotics following 2-stage procedures significantly improved infection-free survival without complications.2

Post-TKA Complications from Opioids

—Amid ongoing concerns about opioid misuse, two studies3 suggested that preoperative opioid use was found to be an independent predictor of increased length of stay, complications, readmissions, and less pain relief following TKA.

References

  1. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M,Ward RJ. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. 2017 May 16;317(19):1967-75.
  2. Frank JM, Kayupov E, Moric M, Segreti J, Hansen E, Hartman C, Okroj K,Belden K, Roslund B, Silibovsky R, Parvizi J, Della Valle CJ; Knee Society Research Group. The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial. Clin Orthop Relat Res.2017 Jan;475(1):56-61.
  3. Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty.2017 Sep;32(9):2658-62. Epub 2017 Apr 12.

PAO Results Hold Up over Intermediate Term

Periacetabular Osteotomy for OBuzzThe Bernese periacetabular osteotomy (PAO) has become the procedure of choice for treating symptomatic acetabular dysplasia. But how long-lasting are its benefits? Quite, according to one of the largest intermediate-term follow-up studies on this procedure, authored by Wells et al. in the February 7, 2018 edition of The Journal of Bone & Joint Surgery.

Among 154 hips (average patient age of 26 years) treated with PAO at a single center between 1994 and 2008, the survival rate, with total hip arthroplasty (THA) as the endpoint, was 92% at 15 years postoperatively. When failure was defined as a conversion from PAO to THA or a symptomatic hip, the hip-preservation rate was 79% at a mean follow-up of 10.3 years.

After carefully analyzing the data to identify factors that contributed to failure or success, the authors discovered that:

  • Hips with fair or poor joint congruency before surgery had 9 times the odds of failing when compared with hips that had good or excellent preoperative joint congruency.
  • Hips with a postoperative lateral center-edge angle of >38° had 8 times the odds of failure.
  • Hips that underwent a concurrent head-neck osteochondraplasty at the time of PAO had a 73% decrease in the odds of failing.

These data suggest that preventing excessive femoral head coverage and secondary impingement resulting from surgery improves hip survival. Consequently, Wells et al. reported that their institution, Washington University School of Medicine, “currently assess[es] for secondary impingement intraoperatively following PAO,…and, if it is present, osteochondroplasty of the head-neck junction is performed to relieve potential secondary femoroacetabular impingement.”

The authors also recommend against managing patients with symptomatic acetabular dysplasia with hip arthroscopy because “it fails to address the underlying pathomechanics found in developmental dysplasia of the hip.”

JBJS 100: Talar Neck Fractures and Elbow Biomechanics

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Fractures of the Neck of the Talus: Long-Term Evaluation of 71 Cases
S T Canale and F B Kelly Jr: JBJS, 1978 Jan; 60 (2): 143
One of the most challenging diagnoses for general orthopedic surgeons and fracture specialists alike is a fracture of the talar neck. In this landmark JBJS article, the authors focused attention on the importance of quality of reduction and created an enduring fracture classification that paralleled complication rates and potential outcomes.

A Biomechanical Study of Normal Functional Elbow Motion
B F Morrey, L J Askew, E Y Chao: JBJS, 1981 Jan; 63 (6): 872
This JBJS article convincingly answered the question about the minimal range of elbow motion needed to accomplish activities of daily living. Using modern 3-dimensional optical tracking technology 30 years after Dr. Morrey’s study appeared, Sardelli et al. found only minimal ROM differences compared to findings in the Morrey study.

With New Technologies, Slow Adoption is Best

MoM for OBuzzThe enemy of the good is the better. It’s an axiom we hear during our surgical training, and it was my first thought when reading the article by Hunt et al. in the February 7, 2018 edition of JBJS.  The authors examine failure rates associated with the rapid adoption and widespread use of metal-on-metal (MoM) total hip arthroplasties (THAs) and hip resurfacings.

Carefully analyzing data from the National Joint Registry for England, Wales and Northern Ireland from 2003 to 2014, Hunt et al. ascertained that MoM hip resurfacings and MoM total hip arthroplasties resulted in 10-year revision rates that were almost 3 and 5 times higher, respectively, than the expected revision rates for standard hip procedures. This meant that within 10 years, there were almost 8 excess revisions for every 100 MoM hip resurfacings and almost 16 excess revisions for every 100 MoM total hip arthroplasties. Just as troubling was the finding that 20% of those excess revisions needed at least one additional revision within 7 years.

As orthopaedic surgeons, we strive to make things better for patients, which may tempt us to try a “new and improved” technology for a nominal (or presumed) improvement in outcome, when the one we are currently using works just fine. It is our responsibility as surgeons not to be blind to the unintended consequences new technologies may have on our patients.

I agree with the blunt directive Hunt et al. issue in the final sentence of their abstract: “This practice of adopting new technologies without adequate supporting data must not be repeated.”

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

A Closer Look at Discrepancies in Medicaid Reimbursements

In the February 7, 2018 issue of The Journal, Lalezari et al. provide a detailed analysis of the variability in state-based Medicaid reimbursements to physicians for 10 common orthopaedic procedures, including hip and knee replacement and 5 spinal surgeries. The discrepancies in reimbursements between states, even bordering states in the same geographic region, are substantial and do not seem to follow any pattern. This phenomenon of reimbursement variability has been mentioned in podium presentations and some less comprehensive reports in the past. However, the authors of this study used a careful, methodological approach to accurately report these differences in a manner that is easy for readers to understand.

There is simply no way to rationalize this degree of variation in Medicaid reimbursement; the magnitude cannot be explained by differences in workload or practice costs because Lalezari et al. adjusted for cost of living and relative value units (RVUs). Nor does Medicaid-reimbursement variability seem to be related to Medicare reimbursement rates, as some states had Medicaid reimbursements that were higher than Medicare reimbursements for all procedures analyzed.

The orthopaedic community should not react directly to the reimbursement discrepancies presented in this article. Rather, orthopaedic surgeons, health system administrators, and patients alike should bring the variability of Medicaid reimbursements to the attention of state and federal policy makers.

Alas, I am not optimistic that this issue will gain a lot of traction given the long list of healthcare-related issues currently on the desks of state and federal lawmakers. Moreover, as the authors mention, these state-based reimbursement rates are likely related to many variables, and Lalezari et al. further observe that “health policy intended to improve access to specialty care should not solely focus on physician reimbursement.” However, consistent communication with elected officials to help explain the impact that these variable rates can have on patient care, accompanied by updated studies like this one every 2 to 4 years, would seem to be a rational response to these data.

Marc Swiontkowski, MD
JBJS Editor-in-Chief