Virtual PT Noninferior to and Less Expensive than Usual Care
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent stu
dy in The Journal of Bone & Joint Surgery, the following commentary comes from Jaime L Bellamy, DO.
The most common complication arthroplasty surgeons worry about after total knee arthroplasty (TKA) is stiffness, which occurs in a reported 15.98% of cases.1 The notion of TKA patients doing their postoperative physical therapy (PT) on their own at home with a “virtual avatar” gives me pause because it might increase the risk of stiffness. However, if patients could save money, make satisfactory progress in the comfort of their own home, and not experience undue knee stiffness, virtual PT technology would be worth it.
In the January 15, 2020 issue of The Journal, Bettger et al. report on a randomized controlled trial that compared virtual to traditional PT after TKA. The authors hypothesized that virtual PT would cost less and would be clinically noninferior to traditional PT. The FDA-approved Virtual Exercise Rehabilitation Assistant (VERA) studied in this trial uses 3-D technology to track patient movement and an avatar (digitally simulated coach) to assist patients through PT exercises. Virtual PT technology like this not only has the potential to reduce costs (particularly travel costs incurred by patients who live in rural areas), but also to help address current and expected therapist shortages.
There were 143 patients in the virtual PT group and 144 in the traditional PT group. Patients randomized to virtual PT had the technology set up in their home prior to surgery. In addition to avatar-assisted home exercises, virtual PT patients had weekly “video visits” with a human therapist.
Bettger et al. found the median 12-week costs for virtual and traditional PT to be $1,050 and $2,805, respectively. Additionally, at 6 weeks, virtual PT was found to be noninferior to traditional PT in terms of patient outcome measures, knee range of motion, and gait speed. At 12 weeks, virtual PT was found to be noninferior to usual care in terms of pain and hospital readmissions.
I am relieved that virtual PT has the potential to provide cost savings, without apparently increasing the risk of knee stiffness. The cost savings and at-home convenience may be especially important for elderly TKA patients who are living on a fixed income and for whom transportation issues are often vexing. I hope technology like VERA continues to contribute to improved patient satisfaction and easier access to PT.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
Reference
- Can administrative data be used to analyze complications following total joint arthroplasty? Clair AJ, et al. J Arthroplasty, 2015;30(9 Suppl):17-20. http://dx.doi.org/10.1016/j.arth.2015.01.060
Elite Reviewer Spotlight: Scott Rodeo
JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.
Name: Scott Rodeo, M.D.
Affiliation:
Co-Chief Emeritus, Sports Medicine and Shoulder Service
Vice Chair of Orthopaedic Research
Co-Director, Orthopaedic Soft Tissue Research Program
Professor, Orthopaedic Surgery, Weill Medical College of Cornell University
Attending Orthopaedic Surgeon, The Hospital for Special Surgery
Head Team Physician, New York Giants Football
Years in practice: 22
How did you begin reviewing for other journals and for JBJS in particular?
I expressed interest to journal editors on the advice of my mentors at The Hospital for Special Surgery.
What is your top piece of advice for those reviewers who aspire to reach Elite status?
Take an active interest in reviewing. Understand that this is a privilege. It is work, but it is very important work. Realize that reviewing helps you abreast of certain specialty areas – this helps you to be a thought leader in the field. Take that responsibility seriously. You know the effort that you put into your own manuscripts – recognize that authors have done the same and they deserve a thoughtful and careful review.
Realize that virtually no other profession advances and changes as rapidly as medicine, and the pace of knowledge production continues to increase. Such continued advances require and demand that we are “stewards” of the constantly expanding knowledge base, and this all starts with publications. Encourage your trainees (residents, fellows) to become true “students” of orthopaedics – encourage them to develop an on-going curiosity for the field. Develop a passion for a certain sub-specialty – become a content expert in that area, which will make you an excellent and valued reviewer. This approach has numerous benefits: it is one of the best ways to avoid “burn-out”, it keeps one engaged over the years, it makes you a better physician/surgeon, and it allows you to be a contributing member to our field.
Aside from orthopaedic manuscripts, what have you been reading lately?
I read the journal Cytotherapy, which is the official journal of the International Society for Cell and Gene Therapy. I also read Nature. Reading these journals provides a window into other, diverse areas of medicine and basic research, and it also helps me understand the current state of the art related to “biologics”, cell therapy, gene therapy, etc. in other areas of medicine.
Learn more about the JBJS Elite Reviewers program.
Pulsed EMF Stimulation for Tendon Healing? Stay Tuned
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.
The effects of electrical currents on early wound healing are well known and studied. The possibility that stimulation of bone formation could be induced with a pulsed electromagnetic field (PEMF) was investigated in the 1960s and translated into clinical use by the 1970s. But the clinical use of PEMF for tendon disorders has not met with similar success.
The precise mechanisms by which these fields affect different tissues is easier to study with the tools we have available today. The measurable parameters of PEMF are intensity, duration, frequency, and duty cycle (percent of time the field is on). Nevertheless, many questions about the possible adverse effects of these fields, their focal delivery, and their possible clinical applications remain unanswered.
In a study of human tendon cells, researchers artificially induced inflammatory cues in cultures using different concentrations of IL‐1β.1 When 1 ng/mL of IL‐1β was used, subsequent cytokine and metalloprotease expression was measured at 1, 2, 3, and 7 days after various PEMF exposures.
The PEMF exposure parameters that most evidently decreased the production of IL-6 and tumor necrosis factor-α (TNF-α) were 4 mT, 5 Hz, and a 50% duty cycle. Those same parameters decreased the expression of TNFα, IL-6, IL-8, COX-2, MMP-1, MMP-2, and MMP-3, while at the same time increasing gene expression of the anti-inflammatory proteins IL-4, IL-10, and TIMP-1. However, the combination of 5 mT and 50% duty cycle had a negative impact on cell viability.
These preliminary results may help guide future investigations, but the authors note that the parameters for optimal PEMF effectiveness on tendon cells may vary with time from insult, further complicating the selection of field parameters.
Reference
- Vinhas A, Rodrigues MT, Gonçalves AI, Reis RL, Gomes ME. Pulsed Electromagnetic Field Modulates Tendon Cells Response in IL-1β-Conditioned Environment. J Orthop Res. 2020 Jan;38(1):160-172. doi: 10.1002/jor.24538. Epub 2019 Dec 10.
Highly Cross-Linked Poly Adds No Benefit to Most TKAs
The preponderance of published orthopaedic evidence supports the use of highly cross-linked polyethylene (HXLPE) in acetabular components for patients undergoing total hip arthroplasty (THA). (See related OrthoBuzz post.) But the literature is filled with conflicting findings about the benefits of HXLPE for those undergoing total knee arthroplasty (TKA). Seeking clarity, in the January 15, 2020 issue of The Journal of Bone & Joint Surgery, Partridge et al. report findings from a registry-based cohort analysis of more than a half-million TKAs, comparing revision rates among those using conventional polyethylene (CPE) with those using HXLPE.
The authors analyzed TKA data captured by the National Joint Registry for England, Wales, and Northern Ireland during the period from 2003 to 2014. Of the >550,000 procedures examined, only about 10% utilized HXLPE. When the authors compared adjusted aseptic revision rates per 100 years observed within the three most common TKA systems in the database (NexGen by Zimmer, PFC Sigma by DePuy, and Triathlon by Stryker), they found no significant differences between HXLPE and CPE after a maximum follow-up of 12 years.
The only notable difference between the two polyethylene types was found in patients <60 years old and/or those with BMI >35 kg/m2, in whom the second-generation Stryker X3 HXLPE showed significantly better survival than its CPE counterpart. In explaining why the benefits of HXLPE seen in THA might not translate to TKA, Partridge et al. contrast the “ball and socket” hip joint with the wear mechanisms in TKA, which involve “rolling, sliding, and rotational motion that potentially put the polyethylene insert at greater risk of wear by delamination, pitting, and fatigue failure.”
The authors conclude that the extra costs of HXLPE bearings for TKA may not be justified for most TKA patients in the intermediate term, but commentator Remy Simon Nizard, MD notes that “other uncontrolled or insufficiently controlled parameters [such as quality of component positioning] may have had an influence on the results.” While Partridge et al. call for “additional follow-up,” Dr. Nizard questions whether full-blown clinical trials investigating alternative bearings in TKA are justified, “given the emerging subject of the burden of research waste.”
What do you think? Comment using the “Leave a comment” button in the box next to the title.
Elite Reviewer Spotlight: Benjamin Miller
JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.
Name: Benjamin J. Miller
Affiliation:
University of Iowa, Iowa City, IA
Years in practice: 9
How did you begin reviewing for other journals and for JBJS in particular?
I began receiving requests to review in fellowship and early clinical practice. Ultimately there are so many requests that you have to be selective about the quality of journal you agree to review for – JBJS has always been of the highest standard and impact.
What is your top piece of advice for those reviewers who aspire to reach Elite status?
Review the article systematically with a degree of skepticism, and focus on the methodology and potential sources of bias or inconsistency. Once a report is in the published literature, it is accepted as fact, and so it is important to be diligent and comprehensive to address any questions a potential reader may have.
Aside from orthopaedic manuscripts, what have you been reading lately?
Just finished Guns, Germs, and Steel – very interesting book, long overdue to read, about how the human world came to be shaped as it is.
Learn more about the JBJS Elite Reviewers program.
What’s New in Adult Reconstructive Knee Surgery 2020
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 OrthoBuzz summaries of these “What’s New” articles. This month, author Michael J. Taunton, MD selected the 5 most clinically compelling findings from the more than 130 studies summarized in the January 15, 2020 “What’s New in Adult Reconstructive Knee Surgery.”
Unicompartmental Knee Arthroplasty (UKA)
—A prospective cohort study of 1,000 Oxford cementless UKAs indicated by standard Kozinn and Scott criteria found that revision-free survivorship at 10 years was 97%. Progression of lateral osteoarthritis and dislocation of the bearing were the most common reasons for revision.1
Pain Management
—Authors of a double-blinded, prospective, randomized study assigned 60 primary total knee arthroplasty (TKA) patients to receive either a continuous adductor canal block or a single-injection adductor canal block with adjuvant agents. They found no between-group differences in pain scores up to 42 hours postoperatively.2
Post-TKA Physical Therapy (PT)
—A prospective, randomized, noninferiority trial demonstrated that 290 post-TKA patients who were randomized to either outpatient PT, unsupervised web-based PT at home, or unsupervised printed-instruction-based PT at home had no difference in knee range of motion or in patient-reported outcomes at 4 to 6 weeks or 6 months postoperatively.3
Infection Prevention
—In a retrospective review of 29,695 total joint arthroplasties, preoperative penicillin allergy testing led to a 1.19% higher rate of infection-free survival at 10 years, principally by allowing more routine use of the prophylactic antibiotic cefazolin.4
Revision TKA
—A retrospective case series found that patients undergoing revision TKA at an age of < 50 years had a survivorship free of re-revision of 66% at 10 years. Regardless of the reason for revision, this population also had a higher risk of mortality than the general population at 10 years.5
References
- Campi S, Pandit H, Hooper G, Snell D, Jenkins C, Dodd CAF, et al. Ten-year survival and seven-year functional results of cementless Oxford unicompartmental knee replacement: A prospective consecutive series of our first 1000 cases. Knee. 2018 Dec;25(6):1231-7. Epub 2018/08/29.
- Turner JD, Dobson SW, Henshaw DS, Edwards CJ, Weller RS, Reynolds JW, et al. Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial. J Arthroplasty. 2018 Oct;33(10):3160-6 e1. Epub 2018/06/16.
- Fleischman AN, Crizer MP, Tarabichi M, Smith S, Rothman RH, Lonner JH, et al. 2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial. Clin Orthop Relat Res. 2019 Jan;477(1):60-9. Epub 2019/02/23.
- Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, et al. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J. 2019 Jun;101-B(6_Supple_B):9-15. Epub 2019/05/31.
- Chalmers BP, Pallante GD, Sierra RJ, Lewallen DG, Pagnano MW, Trousdale RT. Contemporary Revision Total Knee Arthroplasty in Patients Younger Than 50 Years: 1 in 3 Risk of Re-Revision by 10 Years. J Arthroplasty. 2019 Jul;34(7S):S266-S70. Epub 2019/03/03.
JBJS Webinar on Feb. 24: Rotator Cuff Conundrums
Rotator cuff tears account for an estimated 4.5 million patient visits per year in the US, which translates into a $3 to $5 billion annual economic burden. Add to that the pain and disability associated with rotator cuff tears, and it’s understandable that many clinical questions arise regarding how best to help patients manage this common condition.
On February 24, 2020 at 8 pm EST, JBJS will host a complimentary 60-minute webinar focused on 2 frequently encountered rotator cuff dilemmas: surgical versus nonsurgical management, and surgical alternatives for irreparable cuff tears that don’t involve joint replacement.
Bruce S. Miller, MD, MS unpacks the findings from his team’s matched-pair analysis in JBJS, which revealed that patients receiving both surgical and nonsurgical management of full-thickness tears experienced pain and functional improvements—but that surgical repair was the “better of two goods.”
Some patients who opt for nonoperative management end up with a chronic, irreparable rotator cuff tear. Teruhisa Mihata, MD, PhD will present findings from his team’s JBJS study, which showed that, after 5 years, healed arthroscopic superior capsule reconstruction in such patients restored function and resulted in high rates of return to recreational sport and work.
Moderated by Andrew Green, MD of Brown University’s Warren Alpert Medical School, the webinar will feature additional expert commentaries. Grant L. Jones, MD will comment on Dr. Miller’s paper, and Robert Tashjian, MD will weigh in on Dr. Mihata’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!
Safe Retractor Placement during Direct Anterior THA
One of my residency mentors always stressed that orthopaedic surgeons should be “masters of musculoskeletal anatomy.” During his first lecture each July, he would grill the junior residents on muscle origins and insertions, along with innervations. Knowing safe surgical planes helps us avoid complications from neural or vascular injury and increases the likelihood of a successful orthopaedic procedure. With the increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), it is crucial that orthopaedists understand the anatomical implications of that technique.
One key to a successful DAA hip replacement is adequate visualization, which is aided by retractors. However, malpositioned retractors can cause femoral nerve palsy, a potentially serious neurological complication that can delay postoperative rehabilitation. In the January 15, 2020 issue of The Journal, Yoshino et al. report on a cadaveric study that quantifies the distance between the femoral nerve and the acetabular rim at varying points along the rim. Knowing these precise distances could help surgeons make safer decisions about where—and where not—to place retractors.
The authors dissected 84 cadaveric hips from 44 formalin-embalmed cadavers and measured the distance from the femoral nerve to various points along the acetabular rim by using a reference line drawn from the anterior superior iliac spine (ASIS) to the center of the acetabulum. They found the femoral nerve was closest to the rim (only 16.6 mm away) at the 90° point.
In addition, at 90°, the thickness of the iliopsoas muscle and the femoral length (a probable proxy for size of the patient) were positively associated with increased distance to the nerve. Other anatomic factors such as inguinal ligament length, femoral head diameter, and thickness of the capsule were not associated with the nerve-rim distance.
The degree nomenclature used by Yoshino et al. can be correlated to a clock-face representation of the acetabulum, with the 60° point at the 3 o’clock (anterior) position; the 30° point represents a relatively safe location for placement of the anterior inferior iliac spine retractor (see Figure above).
This important anatomic study can help us improve our mastery of musculoskeletal anatomy—and avoid, if possible, placement of retractors at 90° relative to a line drawn from the ASIS to the center of the acetabulum.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Elite Reviewer Spotlight: Andrew Kurmis
JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.
Name: Professor Andrew Kurmis
Affiliation:
Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
Years in practice: Less than 10 years
How did you begin reviewing for other journals and for JBJS in particular?
I received an invitation from an editor, and I was recommended to contact JBJS with regard to potentially reviewing by an esteemed colleague.
What is your top piece of advice for those reviewers who aspire to reach Elite status?
Be sensible with your reviewer workload. A well-done review usually requires good time commitment and effort – this is sometimes hard to achieve if you have too many demands on your plate at the time.
Aside from orthopaedic manuscripts, what have you been reading lately?
I was recently invited to co-author a review article for one of the anaesthetic journals – I have been busily reading anaesthetic manuscripts!
Learn more about the JBJS Elite Reviewers program.
Strong Case for Outpatient Fracture Surgery
Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.
Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.
Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.
On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.
It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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