Archive | October 2014

Editor’s Choice—JBJS Reviews, October 2014

Technological advances in orthopaedic surgery occur steadily and incrementally. However, every so often, something comes along that really changes orthopaedic practice. Such is the case with the introduction of reverse shoulder arthroplasty, which is a unique, novel procedure that can be used to treat a variety of conditions affecting the shoulder. In this month’s issue of JBJS Reviews, George et al. review the use of reverse shoulder arthroplasty for the treatment of proximal humeral fractures.

Proximal humeral fractures, particularly those that occur in osteoporotic bone, can be complex and difficult to manage. While the majority of these fractures can be successfully treated with initial mobilization in a sling followed by return to activities, three and four-part fractures often are associated with poor functional outcomes, including nonunion, malunion, posttraumatic glenohumeral arthritis, and stiffness. Thus, operative interventions such as closed reduction and percutaneous pinning, open reduction and internal fixation with locked or unlocked plates, and locked intramedullary nailing are available options. However, because of the difficulty associated with reduction of three and four-part fractures, open reduction and internal fixation is associated with a high rate of complications.

Nearly sixty years ago, Neer described the use of hemiarthroplasty for the treatment of three and four-part fractures of the proximal part of the humerus. Implants and techniques steadily improved over the ensuing six decades, but the introduction of reverse shoulder arthroplasty may represent a major step forward. In the article by George et al., the use of reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have led to good results after short and intermediate-term follow up. Malunion or nonunion of the tuberosities did not affect the functional result after reverse total shoulder arthroplasty as much as it did after hemi-arthroplasty, but it did lead to decreased postoperative external rotation.

The long-term outcomes of reverse shoulder arthroplasty for the treatment of these fractures still have not been well established, so we probably should not rush to change our practice on the basis of this article alone. Indeed, since the results have been shown to deteriorate as early as six years postoperatively, reverse shoulder arthroplasty should be reserved for older patients and should be avoided in younger patients. Reverse shoulder arthroplasty can be used for the treatment of rotator cuff arthroplasty and recently has gained popularity for the treatment of severe proximal humeral fractures. This article provides a thorough yet concise overview of the application of this novel technique and implant to the treatment of these difficult and complex injuries.

Thomas A. Einhorn, MD, Editor

Active Immune Cells Associated with Quick Recovery from Hip Replacement

The signaling activity of CD14+ monocytes after hip replacement surgery in 32 patients correlated strongly with the patients’ reports of postsurgical pain and function. Stanford researchers reporting in the September 24, 2014 Science Translational Medicine exposed pre- and postsurgical blood samples from the 32 patients to mass cytometry and discovered that people whose CD14+ cells were highly active in specific ways after the operation recovered faster than those whose cells showed low activity.

The current findings can’t be used to predict prior to surgery which individuals will recover quickly or slowly, because the postsurgical CD14+ activity that correlated with clinical outcomes was present only after surgery. But further research on larger numbers of people could lead to “diagnostic signatures” to help predict individual recovery times and to therapeutic targets for improving patient recovery overall.

Nonoperative Knee-Pain Treatments: Acupuncture—No, Bracing—Yes

Two recent studies revealed that valgus bracing may be more effective than acupuncture for treating knee osteoarthritis.

A JAMA study of nearly 300 people 50 and older with chronic knee pain and morning stiffness found that 12 weeks of acupuncture, delivered via both needles and laser,  provided no substantial pain or function benefits at 12 weeks or one year, relative to no acupuncture or a sham laser procedure. One interesting aspect of this study was its so-called Zelen design; participants were consented after randomization, and those randomized to receive no acupuncture were unaware that they were in an acupuncture trial. According to the authors, “Zelen designs can reduce the risk of bias in a treatment trial in which knowledge of the intervention may influence recruitment…and outcomes.”

Conversely, a meta-analysis of six randomized studies totaling more than 400 patients in Arthritis Care and Research found that a valgus knee brace can improve pain and function in people with medial knee osteoarthritis. The analysis examined trials that compared valgus bracing with no orthosis and with other types of orthoses, such as neoprene sleeves. In the former comparison, the valgus brace yielded improvements in both pain and function; in the latter comparison, valgus bracing improved pain but not function. An editorialist commenting on the findings opined that the clinical goal going forward should be to identify those patients who are most likely to benefit from this type of bracing and who will comply with instructions for use.

Does “Prehab” Lower Episode-of-Care Costs in TJA?

Many orthopaedic surgeons still believe that physical therapy (PT) services simply add to the total cost of care without improving patient outcomes. During my orthopaedic education, several knowledgeable attending surgeons said patients can be shown exercises in the orthopaedic clinic and do them on their own to avoid the increased expense of PT services. This belief extended to preoperative PT (“prehab”) to prepare patients for joint-replacement procedures. Until now, the impact of prehab on the total cost of care had not been rigorously evaluated.

In a well-designed study in the October 1, 2014 edition of The Journal, Snow et al. investigated whether preoperative PT affected total episode-of-care cost for hip- and knee-replacement procedures. They used CMS (Centers for Medicare & Medicaid Services) data from 169 urban and rural hospitals in Ohio and gleaned 4733 complete records to answer the question. The outcome measures of interest were utilization of post-acute care in the first 90 days after the procedure and total episode-of-care costs. The study defined post-acute care as admission to a skilled nursing facility, use of inpatient rehabilitation services, or use of home health services.

Nearly 80% of patients who did not receive preoperative PT services utilized post-acute care services, compared with 54% of patients who did receive prehab services. This resulted in a mean cost reduction of $871 per episode (after adjusting for age and comorbidities), with much of the savings accruing from decreased use of skilled nursing facilities. In their discussion, the authors note that prehab in this study generally consisted of only one or two sessions, and they therefore suggest that “the value of preoperative physical therapy was primarily due to patient training on postoperative assistive walking devices, planning for recovery, and managing patient expectations, and not from multiple, intensive training sessions to develop strength and range of motion.”

So it seems that prehab can reduce the overall cost of care in the setting of joint replacement.  Further investigations using commercial insurance datasets to supplement this CMS data will be useful in developing treatment protocols and policies in this age of global payments for episodes of care.

Marc Swiontkowski. MD, Editor-in-Chief, JBJS