Loss of Supination Force with Partial Distal Biceps Avulsion

In the May 5, 2021 issue of JBJS, Tomizuka et al. report the results of mechanical testing in which they quantified the loss of supination and flexion strength after a series of surgical releases designed to simulate traumatic avulsions of the short and long head of the distal biceps tendon.

Reflecting on the clinical implications of their study, the authors note:

Partial tears of the distal biceps tendon can cause substantial disability, yet the mechanical effect of such ruptures is not fully understood. This study showed that a simulated complete short-head tear significantly decreased (p ≤ 0.043) the supination moment arm by 24% in pronation and 10% in neutral.

A mechanical case can be made for early repair of a partial distal biceps tendon tear when the rupture is ≥75% of the distal insertion site.”

Click here for the full JBJS report.

A JBJS Clinical Summary on distal biceps tendon rupture can be found here.

 

Functional Outcomes of Patients with Schizophrenia After Hip Fracture Surgery

Thirty-eight patients with schizophrenia were compared with 170 geriatric patients without schizophrenia who underwent a surgical procedure for a hip fracture.

Read the full article here.

Introducing the OrthoJOE Podcast: 2 Editors, 2 Coffees, and 2 Times the Evidence

JBJS EditorialPodcasts are an increasingly important mode of communication across many segments of society. Our field was perhaps a bit slow to catch on to this movement, but our attention has been awakened. In the Orthopaedic Forum section of this issue, Jella et al. evaluate the growth of podcasts over the previous 9 years within the field of orthopaedic surgery. Of the 94 podcasts that met the inclusion criteria, 62 remained active in the fall of 2020. The pace of introduction of new podcasts in our field has now reached 1 per month.

In collaboration with OrthoEvidence (www.myorthoevidence.com) and its Editor-in-Chief Mohit Bhandari, JBJS (www.jbjs.org) launched a new podcast in January 2021. We have named the podcast OrthoJOE, with the J coming from JBJS and the OE coming from OrthoEvidence. We find the name to be highly relevant, with both of us enjoying fresh coffee while recording these podcasts together every other Tuesday morning. The format of the podcast is highly conversational; some episodes are topical (for example, we recently discussed how our publications managed the explosion of submissions related to COVID-19), whereas others are based on new articles that have appeared in our own publications. The goal, however, is a simple one: to provide insights derived from evidence on top trending issues in OrthoEvidence and JBJS. Although Jella et al. found that 95.7% of active podcasts employ an audio-only format, we are in the process of creating a video version of the podcast that will be available on the JBJS and OrthoJOE websites. Our target audience is international, and our goal is to discuss topics that will be relevant to the worldwide orthopaedic community. As we evolve, we intend to invite guests to participate in topic-based discussions. We also plan to introduce a “mailbag” feature, during which we will discuss audience feedback regarding the opinions that we have expressed during previous episodes. You can listen to OrthoJOE at http://orthojoe.castos.com/ or subscribe through iTunes or wherever you get your podcasts. We invite you to tune in and are interested in your feedback and ideas for discussion. Many thanks in advance.

Mohit Bhandari, MD, PhD, FRCSC
Editor-in-Chief, OrthoEvidence
Marc Swiontkowski, MD
Editor-in-Chief, JBJS

The Challenges of Post-Treatment Care for Patients with Schizophrenia

The worldwide incidence of mental illness seems to be on the rise—and along with it a widespread recognition that this “epidemic” should receive at least as much attention as other health conditions. At the same time, many societies have transitioned to noninstitutionalized care for patients with severe mental health diagnoses. This parallel phenomenon has resulted in more individuals with mental and emotional challenges being cared for by their families and communities.

Orthopaedic surgeons are often asked what the prognosis is for recovery in a patient with a substantive mental health diagnosis, but only a few scholarly attempts have been made to answer that question. In the May 5, 2021 issue of JBJS, Ng et al. provide meaningful data regarding the concomitant diagnosis of schizophrenia among patients in their early 70s who experienced a hip fracture. One-year post-treatment results from this cohort study showed no differences in mortality or surgical or medical complications between patients with and matched patients without schizophrenia. These good-news findings are largely indicative of the high level of care hip fracture patients receive in the authors’ institution, which includes close collaboration among surgeons, geriatrists, physical therapists, and psychiatric clinicians.

However, the 1-year functional outcomes, as measured with the Modified Barthel Index, were worse in the cohort with schizophrenia. I think this is probably related to the difficulty of encouraging patients to participate in standardized rehabilitation processes, challenges associated with self-care, and potentially less-than-optimal social support.

We certainly need more research into determining the best peri- and post-treatment care for orthopaedic patients with severe mental health issues. Ideally, future investigations of these questions will focus on interactions between mental health professionals and surgical and rehabilitation teams. It is my hope that this study by Ng et al. will stimulate that type of research.

Click here for a downloadable Infographic summarizing this study.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Reimbursement for Revision TKA Has Not Kept Pace with Inflation

I was once told that if you don’t have any cases with complications, you either aren’t operating enough or aren’t following your patients. Although we in the orthopaedic community make every effort to minimize the occurrence of patient complications, one that remains difficult to eradicate is periprosthetic joint infection (PJI), which is a leading cause of revision total knee arthroplasty (TKA). The welfare of our patients requires successfully addressing this potentially devastating outcome, but reimbursement for these complex cases has decreased over the past decade.

In the upcoming issue of JBJS, Jella et al. offer insight on temporal trends in Medicare physician reimbursement for revision TKA. They queried the Medicare Physician Fee Schedule Look-Up Tool for pricing information corresponding to 1 and 2-stage revision TKAs and used monetary data from Medicare Administrative Contractors to calculate nationally representative means. The authors evaluated aseptic revision of 1 component, 1-stage revision (aseptic or septic), and both the first and second stages of a 2-stage septic revision.

They found that, from 2002 to 2019, there was a mild increase in the physician fee for each CPT code, with the exception of that for second-stage implantation. However, after adjusting for inflation, total Medicare reimbursements declined for both septic and aseptic revision TKAs (between 23% and 33%), with a significantly greater decline observed for septic revision.

The authors also found that Medicare spending on aseptic revision TKA nearly doubled from 2004 to 2017, while spending on septic revision TKA increased only slightly. They note that a main driver of the discrepancy between septic and aseptic revision may be the reimbursement for the second stage of the former procedure using CPT 27447 instead of a revision procedure code (27487).

We know that an increase in revision TKAs (both septic and aseptic) is expected as the number of primary TKA procedures continues to rise. If reimbursement doesn’t keep pace, it is likely to drive certain surgeons away from tackling the sometimes difficult cases, in turn, leaving our patients with fewer available resources when faced with PJI.

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

A New Venue for Dr. Nelson’s Basic Science Tips

Based on page-view data, the monthly basic science posts from Fred Nelson, MD have been hugely popular on OrthoBuzz over the last 4-plus years.

Now, OrthoBuzz readers can sign up to receive Dr. Nelson’s insights on a weekly basis. The “ORS Connects” e-newsletter, a publication of the Orthopaedic Research Society, has kindly agreed to email OrthoBuzz readers Dr. Nelson’s weekly basic science tips. If you are interested, please email Amber Blake at blake@ors.org with your first and last name and email address.

Because Dr. Nelson’s tips are now available to a wider audience on a more frequent basis, we will no longer be including them in OrthoBuzz. The OrthoBuzz team has thoroughly enjoyed engaging with Dr. Nelson and his fascinating basic-science content. We thank him for his outstanding contributions.

What’s New in Sports Medicine 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 Guest Editorial summaries.

This month, co-author Rachel M. Frank, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the April 21, 2021 “What’s New in Sports Medicine.”

Anterior Cruciate Ligament (ACL)

–Two-year results from the STABILITY randomized controlled trial (RCT)1 comparing single-bundle, hamstring-autograft ACL reconstruction with or without lateral extra-articular tenodesis demonstrated a

4% graft failure in the tenodesis group versus 11% in the non-tenodesis group. Both groups had similar levels of sports activity at 2 years.

Meniscus

–A matched cohort comparison of 45 posterior medial meniscal root tears2 treated either nonoperatively, with partial meniscectomy, or with root repair found the following at a mean of 74 months:

  • No significant between-group differences in patient-reported outcomes (IKDC and Tegner scores)
  • Progression to arthroplasty in 60% of those who underwent partial meniscectomy, 27% of those treated nonoperatively, and 0% of those who underwent root repair
  • Less arthritic progression on radiographs in the root-repair group relative to the other 2 groups

Rotator Cuff

A multicenter Level-II study compared 96 patients with a rotator cuff tear who underwent nonoperative treatment with 73 similar patients who underwent a surgical procedure. At approximately 3 months, patients in the nonoperative group had significantly better outcomes, but after 1 to 2 years, surgical patients did better in terms of ASES and SPADI scores.

Hip Preservation

–A meta-analysis of 3 RCTs (n=650 patients)3 comparing physical therapy with hip arthroscopy for treating femoroacetabular impingement found the following:

  • Greater improvement in the arthroscopy group (as measured with the International Hip Outcome Tool-33) at 10 months
  • No between-group differences in 1 of the 3 RCTs at 1 or 2 years when the Hip Outcome Score-ADL and -Sports scales were used

The authors concluded that “hip arthroscopy had significantly superior short-term outcomes.”

Long Head of the Biceps Tendon

–A prospective RCT4 compared biceps tenodesis with biceps tenotomy in >100 patients with pathology of the long head of the biceps tendon. At the 2-year follow-up, the authors found no between-group differences in cramping, elbow flexion strength, or supination strength. The only significant difference was the incidence of a cosmetic Popeye deformity, which was associated with a 3.5 times higher risk after tenotomy.

References

  1. Getgood AMJ, et al. for the STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med.2020 Feb;48(2):285-97. Epub 2020 Jan 15.
  2. Bernard CD, Kennedy NI, Tagliero AJ, Camp CL, Saris DBF, Levy BA, Stuart MJ, Krych AJ. Medial meniscus posterior root tear treatment: a matched cohort comparison of nonoperative management, partial meniscectomy, and repair. Am J Sports Med.2020 Jan;48(1):128-32. Epub 2019 Nov 25.
  3. Dwyer T, Whelan D, Shah PS, Ajrawat P, Hoit G, Chahal J. Operative versus nonoperative treatment of femoroacetabular impingement syndrome: a meta-analysis of short-term outcomes. 2020 Jan;36(1):263-73.
  4. MacDonald P, Verhulst F, McRae S, Old J, Stranges G, Dubberley J, Mascarenhas R, Koenig J, Leiter J, Nassar M, Lapner P. Biceps tenodesis versus tenotomy in the treatment of lesions of the long head of the biceps tendon in patients undergoing arthroscopic shoulder surgery: a prospective double-blinded randomized controlled trial. Am J Sports Med.2020 May;48(6):1439-49. Epub 2020 Mar 30.

Home in on Bone Health in Patients with Fragility Fractures

AOA_OwnTheBone_Logo_12.17_Final_RGB-stackedOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from James Blair, MD, in response to a recent edition of the OrthoJOE podcast.

Geriatric hip fractures are among the fastest growing subset of injuries that orthopaedic surgeons treat. Often these injuries are the first objective signs of osteoporosis. While the surgical treatment of these fractures continues to improve, orthopaedic surgeons may be neglecting their role in triggering investigations into the underlying bone health of these patients.

A recent insurance database analysis by Sara Cromer, MD, presented at the Endocrine Society’s 2021 Annual Meeting, demonstrated a substantial drop in the use of bone-directed medications over the past decade, despite the rise in the number of osteoporotic-related fractures. It is unclear why this trend has occurred, but the main concern is that new diagnoses of osteoporosis are being overlooked.

This concern arose during a recent OrthoJOE podcast focused on distal radial fractures. OrthoEvidence Editor-in-Chief Dr. Mo Bhandari alluded to the confusion over who is responsible for bone-health intervention during treatment of a fragility fracture: the inpatient orthopaedic surgery team, the hospitalist, or the patient’s family physician or internist. “The thought is that someone is going to manage this,” Dr. Bhandari states. “Everyone is looking at everyone else, and it’s not happening.”

In fragility-fracture cases, JBJS Editor-in-Chief Dr. Marc Swiontkowski emphasized the importance of orthopaedic surgeons initiating investigations into their patients’ bone quality with evaluations of vitamin D, ionized calcium, and parathyroid and thyroid hormone levels. “We are failing miserably at this,” Dr. Swiontkowski laments, recalling seeing 3 elderly patients in a single day with a hip fracture that was preceded by a distal radial fracture a decade earlier–with no bone-health investigation ever performed at that time.

Initiatives like the American Orthopaedic Association’s (AOA’s) “Own The Bone” program try to raise awareness of our broader responsibility as orthopaedic surgeons when treating osteoporotic fractures such as those of the proximal femur, distal radius, and vertebrae. Drs. Bhandari and Swiontkowski strongly believe that the orthopaedic surgeon must claim ownership of their patients’ bone health, not necessarily by medically managing such cases, but by initiating a dialog with the patient’s primary care physician and/or rheumatologist/endocrinologist.

Click here to find out more about the AOA’s “Own The Bone” program.

James A. Blair, MD is the Director of Orthopaedic Trauma at the Medical College of Georgia at Augusta University and a member of the JBJS Social Media Advisory Board.

Targeted Muscle Reinnervation Helps Reduce—and Prevent—Pain in Amputees

Symptomatic neuromas have long been a problem for amputees, interfering with prosthetic comfort and causing residual pain that often requires treatment. During the last 15 to 20 years, surgeons have used targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures to improve symptoms from neuromas. In TMR, surgeons transfer a mixed or sensory nerve to a “target” transected motor nerve to prevent disorganized axonal growth. RPNI is a less complicated procedure during which the free nerve end is implanted into a denervated free muscle graft, again to decrease disorganized sprouting of axons.

Advances in amputee care at US military centers, driven largely by recent overseas conflicts, have shown anecdotally that TMR and RPNI prevent neuroma formation when used prophylactically during initial amputation, and that they also relieve pain when used as secondary treatment for existing neuromas. In the April 22, 2021 issue of The Journal, Hoyt et al. reviewed records from Walter Reed National Military Medical Center to evaluate changes in pain scores, symptom resolution, and frequency of complications when TMR and/or RPNI were utilized.

The authors analyzed 87 nerve interface interventions in 80 lower extremity amputations that had at least 6 months of follow-up. Fifty-nine of the procedures (68%) were done to treat symptomatic neuromas at a median of 6.5 years after amputation, while 28 procedures (32%) were done for primary prophylaxis. Hoyt et al. found that the sciatic nerve was most likely to develop symptomatic neuromas after amputations at or above the knee, while the tibial and peroneal nerve distributions were most commonly symptomatic after amputations distal to the knee. TMR was utilized alone in 85% of the cases, and surgeons used RPNI most frequently to prevent pain in the sural and saphenous nerves.

Overall, symptom resolution after all procedures was 92% at the final follow-up. VAS pain scores improved from 4.3 to 1.7 points in the delayed-treatment group and did not vary by amputation level. The final mean pain score in the primary-prophylaxis group was 1.0 ±1.9. There were no significant differences in pain outcomes between the primary and delayed groups, but 6 patients in the delayed cohort required revision for residual limb or phantom limb pain. In patients with transtibial amputations, failure to address an asymptomatic tibial nerve during delayed TMR resulted in an increased risk of revision surgery.

Although retrospective in nature, this study shows some encouraging early data to support the primary and secondary use of TMR/RPNI in amputee care. More research is required to determine whether these results in wounded warriors can be replicated in a civilian amputee population.

Click here for a Commentary on this study by Ann R. Schwentker, MD.

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

Better TKA Outcomes When Depression Is Addressed

In the past decade, we’ve learned through a multitude of studies that patient factors can have a substantial impact on the outcomes of orthopaedic interventions. Medical comorbidities, body habitus, and level of fitness are just a few factors we have evaluated. We also now better understand the impact of socioeconomic status and education level on access to care and the results of that care. And importantly, contemporary research is giving us a more complete picture of the relationship between a patient’s mental status and functional outcomes.

Geng et al. provide further insight into this relationship in a recent JBJS report. In a randomized controlled trial conducted at their institution in the People’s Republic of China, the authors investigated whether psychological intervention for patients with depression improved outcomes of total knee arthroplasty (TKA). Among 600 patients prospectively screened, 53 were identified with depressive disorders; 49 remained in the final analysis (24 randomized to standard TKA care and 25 randomized to perioperative psychotherapeutic interventions administered by a mental health professional). Those in the intervention group not only had a significantly higher rate of satisfaction compared with the control group, but they also showed greater improvements in functional outcome scores, range of motion, and scores on depression scales.

As Pablo Castañeda, MD emphasizes in a related Commentary on this article, “Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes.” I know that mental health concerns—especially depression—can be difficult to identify during all-too-brief orthopaedic consultations with patients. But they will reap important benefits if we learn to better recognize depression, engage patients in conversations related to mental health, and team with our mental health colleagues for referrals and support. The study by Geng et al. points to a model of care with potential for wider adoption. Considering our community of highly motivated orthopaedic surgeons who are dedicated to the holistic welfare of patients, I believe it is possible to raise our skills in this area close to the level of our ability to examine a knee radiograph.

Marc Swiontkowski, MD
JBJS Editor-in-Chief