Ten-Year Results of the BIRMINGHAM HIP Resurfacing Implant System 

There have been 3 historic cycles of interest in surface replacement of the hip in the last 40 years. The second cycle occurred in the 1980s into the 1990s, when very high failure rates were reported. Biomaterial and design advancements fueled the most recent cycle of interest, which began 12 to 15 years ago. However, the enthusiasm that occurred at the advent of this most recent cycle ebbed as it became increasingly apparent that patient selection is critical and that the fairly difficult hip resurfacing procedure requires experience to reproducibly place the implants correctly. 

In the latest issue of JBJS,  Su et al. report the 10-year results of the post-market-approval study of the BIRMINGHAM HIP Resurfacing (BHR) implant system, a metal-on-metal system approved by the U.S. Food and Drug Administration in 2006. The study included a cohort of 280 hips (253 patients) undergoing primary BHR procedures across 5 sites. The mean patient age at the time of surgery was 51 years; 74% of the BHRs were implanted in male patients, and 95% of the hips had a diagnosis of osteoarthritis.  

Among the findings: 

  • 10-year survivorship free from all-cause component revision was 92.9%. Among male patients <65 years of age at the time of the procedure, the rate was 96%. 
  • Twenty hips underwent revision (at a mean of 5 years).  
  • Whole-blood cobalt and chromium levels were higher at 1 year after surgery compared with preop levels; they remained stable through 5 years, and then decreased somewhat at 10 years.  
  • Improvements in the EQ-5D visual analogue scale score and Harris hip score were noted at 1 year and were maintained through 10 years.  

These outcomes are encouraging, but as Su et al. point out, the cohort is not representative of typical total hip arthroplasty populations, who tend to be older and include a greater percentage of female patients. Moreover, the surgeons who performed the procedures were all experienced. Patient selection remains key, with younger male patients being the best candidates. Data such as these can help sharpen our focus as we refine arthroplasty concepts for further improvement in patient outcomes. 

For additional perspective on this study, see the commentary by Timothy S. Brown, MD 

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

A Creative Approach to COVID-Era Journal Clubs

All recipients of the JBJS Robert Bucholz Journal Club Grant are asked to complete an end-of-year survey that includes a question about how they used the grant money. This interesting reply comes from Kyle Morgenstern, MD, an orthopaedic resident at the University of Minnesota.

Resident engagement in journal clubs has been a challenge over the last couple of years. In our hard-working residency it is tough for residents to take time out of their evening every month for journal club. Formerly, we used the JBJS grant funds to purchase food and drinks for attendees. But with the virtual nature of journal club this past year, we saw our attendance start to slide and had to find other ways to recruit residents and boost morale.

So at the beginning of the COVID era, we utilized the grant money to purchase items awarded to attendees for their participation. I figured that if we couldn’t offer food and drink in person, we could at least do it virtually, and we awarded DoorDash gift cards.

Later, we transitioned to awarding a textbook to one presenter at each Journal Club. The winner of the textbook for best presentation was selected via an anonymous Zoom-poll vote of the faculty in attendance. We do Journal Club “Specialty Nights,” so, for example, we awarded Operative Techniques in Shoulder and Elbow Surgery during our shoulder-and-elbow night.

Those who received a textbook were quite thankful, especially those entering their trauma rotations or going into a particular subspecialty. I think this is something we will continue to budget for in the future, as we return to in-person meetings coming out of the pandemic.”

Applications for the 2021-2022 Robert Bucholz Journal Club grant will be available soon. Please stay tuned!

Decrease in Inflation-Adjusted Medicare Reimbursement for Revision THA 

In a study now reported in JBJS, Acuña et al. analyzed Medicare reimbursements associated with revision total hip arthroplasty (THA) procedures. After adjusting for inflation, they found that the mean physician fee reimbursement for revision THA due to aseptic complications declined by a mean of 27% for femoral component revision, 27% for acetabular component revision, and 28% for both-component revision from 2002 to 2019. For 2-stage revision due to infection, they found that mean reimbursement fell by 19% and 24% for the explantation and reimplantation stages, respectively.  

The total decline in reimbursement for revision THA due to infection ($1,020.64 ± $233.72) was significantly greater than that for revision due to aseptic complications ($580.72 ± $107.22) (p < 0.00001). 

Reflecting on their investigation, the authors note: 

In light of persistent cost pressures and discussions surrounding the future of total hip arthroplasty reimbursement, our study explores temporal trends in the Centers for Medicare & Medicaid Services (CMS) physician fee schedule for revision THA procedures. Our findings, showing a significantly larger decline for septic revision THA reimbursements compared to their aseptic counterpart, may have important implications for ongoing discussions surrounding the CMS physician fee schedule.” 

They conclude in their study that, “continuation of this trend [of decreased reimbursement] could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.” 

Click here for the full JBJS report. 

A recent OrthoBuzz post on reimbursement for revision TKA can be found here. 

 

What’s New in Orthopaedic Trauma 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported 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 Mai P. Nguyen, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the recently published “What’s New in Orthopaedic Trauma.” 

Proximal Humeral Fracture 

–The DelPhi (Delta prosthesis-PHILOS plate) study, a multicenter, single-blinded, randomized controlled trial (RCT), evaluated the outcomes of reverse shoulder arthroplasty vs open reduction and internal fixation for displaced proximal humeral fractures in elderly patients. The results favored reverse shoulder arthroplasty (mean 2-year Constant-Murley score of 68.0 vs. 54.6 points for the 2 groups, respectively). 

Hip Fracture 

–An RCT comparing hemiarthroplasty with or without cement in elderly patients with a displaced intracapsular fracture of the hip found better results for cemented hemiarthroplasty1. There was a trend toward a higher mortality rate in the uncemented group, and although pain scores and reoperations were similar between the groups, better recovery of mobility was noted for the cemented group. 

Proximal Femoral Fracture 

–Another recent RCT investigated the efficacy of a preoperative fascia iliaca compartment block (FICB) for patients with proximal femoral fractures (neck, intertrochanteric, or subtrochanteric regions)2. Lower morphine consumption (0.4 vs 19.4 mg; p = 0.05) and greater patient-reported satisfaction (31%; p = 0.01) were noted for the FICB cohort. 

Ankle Fracture 

–Among patients treated for unstable, rotational-type ankle fractures, a prospective RCT compared weight-bearing at 2 vs 6 weeks postoperatively3. Early weight-bearing at 2 weeks was associated with higher EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) scores at the 6-week follow-up. No difference, however, was seen at later follow-up time points. 

Recovery After Trauma 

–The impact of trauma recovery services (TRS), which provide education and psychosocial support to patients with trauma and their families, was assessed in a recent study4. A total of 294 patients with operatively treated extremity fractures were prospectively surveyed. Injury, social, and demographic characteristics were studied for a possible association with patient-satisfaction scores. Use of TRS was the greatest predictor of better overall care ratings. 

References 

  1. Parker MJ, Cawley S. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip: a randomized trial of 400 patients. Bone Joint J. 2020 Jan;102-B(1):11-6. 
  2. Thompson J, Long M, Rogers E, Pesso R, Galos D, Dengenis RC, Ruotolo C. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2020 Jan;34(1):49-54. 
  3. Schubert J, Lambers KTA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-65. Epub 2020 Mar 6. 
  4. Simske NM, Benedick A, Rascoe AS, Hendrickson SB, Vallier HA. Patient satisfaction is improved with exposure to Trauma Recovery Services. J Am Acad Orthop Surg. 2020 Jul 15;28(14):597-605.

Changes in 24-Hour Physical Activity Patterns and Walking Gait Biomechanics After Primary Total Hip Arthroplasty

Together with improvements in self-reported pain and perceived physical function, patients had significantly improved gait function postoperatively.

Read the full article here.

Minimally Invasive Hallux Valgus Correction: Promising Outcomes of Third-Generation Technique  

The field of orthopaedics continually seeks to improve our ability to help patients return to optimal function as quickly and efficiently as possible. New surgical techniques aimed at better outcomes, faster recovery, and smaller (and hopefully less painful) scars are regularly being developed and evaluated. The concept of minimally invasive surgery (MIS) has been around for some time, with newer techniques being utilized in multiple subspecialties. Foot and ankle surgery is no exception, with procedures including MIS for hallux valgus deformity correction. While early generations of such procedures were fraught with complications, newer, third-generation MIS (involving screw fixation of a distal metatarsal osteotomy site) has shown promising early results, with a documented learning curve of 20 to 50 cases.

In the July 7, 2021 issue of JBJSLewis et al. present their results from a consecutive series of third-generation minimally invasive chevron and Akin osteotomies (MICA) in the treatment of hallux valgus. Patient-reported outcome measures (PROMs) collected preoperatively and at a minimum of 2 years postoperatively as well as radiographic outcomes and complications were evaluated.

From the initial series of 333 feet (230 patients), PROMs data were available for 292 feet, or 87.7% (200 patients). PROMs utilized included the Manchester-Oxford Foot Questionnaire (MOXFQ), a tool specifically validated for patients undergoing hallux valgus surgery; the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index and EuroQoL visual analogue scale (EQ-VAS), validated quality-of-life measures; and a VAS for pain.

The authors found a significant improvement (greater than the minimal clinically important difference) in each domain of the MOXFQ. They also noted a significant improvement in the VAS-pain score and the EQ-5D-5L Index.

There was an overall 21.3% complication rate, with only 7.8% of the cases requiring a return to the operating room, most frequently for screw removal (6.3%). The operating surgeon was outside the reported learning curve, having previously performed approximately 100 MICA procedures, but there were still complications that can help guide the physician-patient discussion regarding the use of the MICA.

Although radiographic follow-up did not routinely go beyond 6 weeks, the authors found significant improvement in radiographic measures. With >25% of the preoperative deformities being classified as “severe,” the findings suggest the potential utility of the procedure for patients with a range of deformity severity.

This series—which the authors note is the largest of the third-generation MICA technique— opens the door for possible head-to-head comparison with traditional hallux valgus surgery via a randomized trial to further define the role of MICA in the treatment of patients with hallux valgus.

A Video Summary of this article can be found here.

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

The Cost-Effectiveness of Fragility-Fracture Screening and Prevention

After nearly 2 decades, the orthopaedic community has made a good start on assuming our responsibility in the diagnosis of osteoporosis after a patient’s initial low-energy fracture. We are seeing a positive impact from programs such as the American Orthopaedic Association’s “Own the Bone” initiative as well as from the expanded creation of multidisciplinary fracture liaison services, through which patients who sustain a fragility fracture can receive appropriate follow-up to reduce the risk of subsequent injury.   

There is still work to do to convince the wider orthopaedic surgeon community that leadership on this issue falls in our area. Primary care, rheumatology, and physiatrist practices are overwhelmed with patients with other clinical issues that require their resources. At the same time, it is easier to identify patients who may need treatment for low bone density during their initial encounter in the orthopaedist’s office or during a hospital admission. There is good evidence to suggest that patients are much more receptive to following through with laboratory testing and bone-density screening when they are being treated for a serious metaphyseal fracture.  

In the July 7 issue of JBJS, Saunders et al. examine the cost-effectiveness of a fracture liaison service, presenting their findings of a cost analysis of the Fracture Screening and Prevention Program (FSPP) of Ontario, Canada. Established in 2007, the FSPP was gradually implemented in 37 outpatient fracture clinics in the province; in 2011, the initial education-communication model was replaced by a more intensive strategy, with fracture risk assessment and referrals to specialists being added.  

The researchers’ goal was to determine the cost-effectiveness of the current FSPP compared with usual care (no program). They developed a Markov model and simulated a cohort of patients with a fragility fracture starting at 71 years of age, with model parameters obtained from the published literature and the FSPP.  

The authors concluded that, from the public health-payer perspective, the program is indeed less costly (by $274) and more effective (by 0.018 quality-adjusted life-year) over the lifetime of the patient. Read the full report here.  

We have seen that fracture liaison services can be beneficial to the individual patient. Data such as those from Saunders et al. can help to quantify—for payers and health systems—the value of those services, as our specialty takes on the responsibility of ensuring that patients receive appropriate screening for fracture risk and prevention.

Marc Swiontkowski, MD 
JBJS Editor-in-Chief 

Contralateral Limb Function Before THA: An Indicator of Postop Gait Speed 

In a prospective case-control study reported in JBJS, Ohmori et al. evaluated factors related to postoperative gait speed in patients with osteoarthritis undergoing total hip arthroplasty. They found that the preoperative, contralateral-side OLST (one-leg standing time) was a significant factor (p < 0.001) for postoperative comfortable gait speed. They also found that preoperative, contralateral-side knee extensor strength was a significant factor (p = 0.018) for postoperative maximum gait speed. 

Reflecting on their findings, the authors note: 

THA is a procedure that typically has a good a postoperative prognosis. However, some patients do not have sufficient satisfaction. Investigating reasons for this, we found that the functional status of the nonoperative lower limb is an important factor. 

Surgical intervention before lower-limb function on the contralateral side declines, or a preoperative rehabilitation intervention on the contralateral side, may improve the THA outcome.” 

Click here for the full JBJS report. 

Journal Club Resident Spotlight: Jui-Yo Hsu

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 literatureClick here for more information.

Name: Jui-Yo Hsu

Affiliation: National Taiwan University Hospital

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

In March 2021, we hosted a spine journal club focusing on adolescent idiopathic scoliosis (AIS). It was our pleasure to have Prof. Andrew J. Schoenfeld, deputy editor of JBJS, join our discussion. His remarkable advice and unique insight inspired in-depth discussion. Our advisor and moderator, Prof. Shu-Hua Yang (楊曙華), chairperson of Taiwan Spine Society, who is also a pioneer in the field of AIS research, also provided great support to our journal club. The paper we presented was “Selecting the ‘Touched Vertebra’ as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves” (J Bone Joint Surg Am. 2020 Nov 18;102(22):1966-1973.) by Beauchamp, et al. All the faculty and residents were highly involved in the discussion. Due to the high relevance of this topic to clinical decision making in surgical correction of AIS, both Prof. Schoenfeld and Prof. Yang shared their viewpoints and precious clinical and surgical experiences with the audience.

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

First, it’s important to keep the journal club intriguing to the participants. Therefore, choosing a good topic plays a key role. Residents will be more involved if the topic is clinically important, related to a familiar surgery, or connects to their own ongoing research. Second, because knowledge of the topic may vary between senior and junior residents, we assign one of our senior residents to provide background knowledge before the discussion. Reading the article and preparing in advance are required for every participant, and we also encourage everyone to come up with several questions before the journal club. Finally, support and participation from the faculty are crucial to the journal club. They can provide clinical experiences to residents and provoke further discussion. It is even more beneficial if the participants discuss their own cases with both colleagues and instructors.

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

In Taiwan, fortunately we were able to maintain normal lives and all residents and staff were able to participate in the journal club in person, despite the global pandemic. However, due to a local outbreak in Taiwan in early May 2021, restrictions were imposed on indoor gatherings. We therefore decided to host our journal club online. In fact, residents were more engaged in online journal club. Using the chatroom feature, residents were able to ask question at any time without interrupting the speaker, and supplementary materials could be shared by anyone at any time. I believe online meetings may become mainstream in the post COVID-19 era.

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

I have been reading Cribsheet: A Data-Driven Guide to Better, More Relaxed Parenting, from Birth to Preschool, by Emily Oster. It is a remarkable and useful book for first-time parents. I just welcomed my first child in April 2021, and this book provides practical advice in parenting with enormous medical references. Surprisingly, it was written by an economist. I feel more relieved and confident in parenting my son after reading this book.

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

JBJS Clinical Classroom is very helpful in terms of learning orthopaedic knowledge for both junior and senior residents. Its innovative design makes it very easy and efficient to review previously learned concepts. The content is also very neat but with wide coverage across different specialties, which is also very helpful for orthopaedic board exam preparation.

What’s New in Spine Surgery 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported 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 Jacob M. Buchowski, MD, MS summarizes the 5 most compelling findings from the studies highlighted in the recently published “What’s New in Spine Surgery.” 

Degenerative Cervical Myelopathy

–In a multicenter, double-blinded, placebo-controlled, randomized phase-3 trial, investigators found no additional benefit from riluzole use with regard to functional outcome scores among patients who underwent decompression and fusion for cervical myelopathy1. The primary outcome of interest was the change in the modified Japanese Orthopaedic Association (mJOA) score at 6 months. 

Dysphagia After Multilevel ACDF

–A Level-I double-blinded randomized controlled trial demonstrated a significant decrease in the severity of dysphagia after multilevel anterior cervical discectomy and fusion (ACDF) among patients who received local intraoperative corticosteroids (56 in the treatment group vs 53 in the control group)2. 

Preop. Epidural Steroid Injection and Postop. Infection 

–A retrospective study of patients who underwent lumbar spine surgical procedures for radiculopathy and/or spinal stenosis3 found that: 

  • In the decompression group, there was no significant difference in the postoperative infection rate between those who had a preoperative epidural steroid injection (2,957 of 9,903) and those who did not.  
  • Among those who underwent fusion, there was a significantly higher rate of infection (2.68%) for those who had preoperative epidural steroid injection (1,383 of 5,108) vs those who did not (1.69%).  
  • In the fusion group, there was a significantly higher rate of infection for those who had a steroid injection within 30 days or >90 days preoperatively, but patients with injection between 30 and 90 days preoperatively had no increased risk of postoperative infection. 

Adolescent Idiopathic Scoliosis (AIS)

–In a Level-IV study, investigators examined the relationship between thoracic morphology and pulmonary function in patients with AIS (mean age, 15.6 years)4. They found a strong positive correlation between the costophrenic angle distance and forced vital capacity, FEV1, vital capacity, and total lung capacity, suggesting that the costophrenic angle distance can be used to assess pulmonary function outcome. Their findings also suggest that an apical vertebral deviation ratio of >0.2 is associated with moderate to severe impairment of lung function. 

Early-Onset Scoliosis (EOS) 

–In a cross-sectional study of prospectively enrolled patients across multiple centers, investigators examined the influence of the classification of EOS etiology, radiographic parameters, and medical comorbidities on the Early Onset Scoliosis Questionnaire (EOSQ), a measure of health-related quality of life. Scores were lower in many EOSQ domains for patients with neuromuscular and syndromic etiologies. The total and subdomain scores were similar between patients with congenital and idiopathic EOS.  

References 

  1. Fehlings MG, Badhiwala JH, Ahn H, Farhadi HF, Shaffrey CI, Nassr A, Mummaneni P, Arnold PM, Jacobs WB, Riew KD, Kelly M, Brodke DS, Vaccaro AR, Hilibrand AS, Wilson J, Harrop JS, Yoon ST, Kim KD, Fourney DR, Santaguida C, Massicotte EM, Kopjar B. Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial. Lancet Neurol. 2021 Feb;20(2):98-106. Epub 2020 Dec 22. 
  2. Kim HJ, Alluri R, Stein D, Lebl D, Huang R, Lafage R, Bennett T, Lafage V, Albert T. Effect of topical steroid on swallowing following ACDF: results of a prospective double-blind randomized control trial. Spine (Phila Pa 1976). 2021 Apr 1;46(7):413-20.  
  3. Kreitz TM, Mangan J, Schroeder GD, Kepler CK, Kurd MF, Radcliff KE, Woods BI, Rihn JA, Anderson DG, Vaccaro AR, Hilibrand AS. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine (Phila Pa 1976). 2021 Feb 1;46(3):E197-202. 
  4. Deng Z, Luo M, Zhou Q, Yang X, Liu L, Song Y. Relationship between pulmonary function and thoracic morphology in adolescent idiopathic scoliosis: a new index, the “apical vertebra deviation ratio”, as a predictive factor for pulmonary function impairment. Spine (Phila Pa 1976). 2021 Jan 15;46(2):87-94.