Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
The most lasting legacy from William Harris’s classic evaluation of post-traumatic mold arthroplasty published in 1969 is embodied in the paper’s subtitle, which refers to “a new method of result evaluation.” This end-result analysis evaluated 39 mold arthroplasties performed to treat traumatic arthritis at Massachusetts General Hospital between 1945 and 1965. Based on this series, the author at the time concluded that mold arthroplasty was the treatment of choice for most patients who require surgery for traumatic arthritis.
However, the most enduring part of this article can be found in the methods section, where the author proposed a hip score, a “single, reliable figure” designed to be equally applicable to different hip problems and different treatments. Dr. Harris designed the 100-point system to be reproducible and reasonably objective, giving a maximum of 44 points to a pain category, 47 points to functional capacity, 5 to range of motion, and 4 to absence of deformity. By using the scores pre- and postoperatively for this series of mold-arthroplasty patients, the author demonstrated how the new rating appeared to give a more accurate assessment of patients, relative to the Shepherd and Larson methods that were widely used at the time.
Dr. Harris broke down the function part of the score into daily activities (including stairs, socks and shoes, and comfort while sitting) and gait (with or without limping, with or without support). Over the years, this scale, along with the Postel Merle d’Aubigné developed in the 1950s, became the international gold standards to evaluate the pre- or postoperative state of the hip joint during everyday life. Not surprisingly, 46 years after its original publication, Dr. Harris’s paper remains the highest cited paper in the hip and knee arthroplasty literature, with nearly 2,500 citations.
Although the findings in this study focused mainly on post-traumatic arthritis treated by mold arthroplasty, the evaluation system proposed in the paper is used today in routine evaluations at almost every orthopedic center involved in hip arthroplasty. It’s used to clinically evaluate the hip joint before surgery and to evaluate the result after surgery at regular short-term follow-ups. It has also been used over the course of decades to evaluate the long-term performance of replaced joints. In addition, it is the clinical tool we use to compare various surgical techniques, different hip prosthesis designs, and case series from different institutions.
More recently, investigators have highlighted the importance of patient-reported measures of outcomes to better appreciate patient expectations before hip arthroplasty and to better evaluate patient satisfaction after surgery. Regardless of whether the primary goal of the operation is to relieve pain or get a person back on the athletic field, I think the system established by William Harris will remain the baseline for all arthroplasty surgeons, even if future scoring systems routinely incorporate patient-reported outcomes or quality-of-life measures.
Jean-Noel A. Argenson, MD, PhD
JBJS Deputy Editor for Adult Hip and Knee Reconstruction
Every 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. Here is a summary of selected findings from Level I and II studies cited in the May 20, 2015 Specialty Update on foot and ankle surgery:
Talar and Calcaneal Fractures
- A prospective randomized study comparing the sinus tarsi approach with the minimally invasive approach to the calcaneus found significantly fewer wound healing complications and shorter operative times with the minimally invasive longitudinal approach, but better outcomes were noted with the sinus tarsi approach for Sanders type-IV fractures.
- An RCT comparing outcomes of operative and nonoperative treatment for displaced intra-articular calcaneal fractures found no between-group differences at one year, but a trend toward better pain scores and function was noted in the operative group at eight to twelve years.
- A prospective randomized study of treatments for severe lateral ankle sprains compared a walking boot with restricted joint mobilization for three weeks with immediate application of a functional brace. No between-group differences in pain scores or development of mechanical instability were found, but the immediate functional-brace group had better function scores and shorter recoveries.
- A randomized trial comparing neuromuscular training, bracing, and a combination of the two for managing lateral ankle sprains concluded that bracing is the dominant secondary preventive intervention.
Total Ankle Arthroplasty
- A Level II study comparing total ankle arthroplasty (TAA) with ankle arthrodesis found that both procedures improved gait postoperatively, but TAA came closer to restoring a normal gait.
- A Level II study comparing fixed and mobile-bearing TAA devices found nearly equivalent improvements in pain and function.
- A Level I study looking at TAA outcomes in relation to preoperative coronal-plane malalignment found that results were similar for ankles with a preoperative coronal-plane varus deformity of ≥10° and those with <10° of varus deformity.
Ankle and Hindfoot Arthrodesis
- A pilot RCT comparing B2A-coated ceramic granules with autograft in foot and ankle arthrodesis found that the B2A approach produced a 100% fusion rate, compared with a 92% rate in the autograft group.
- A Level II study found that weight-bearing cast immobilization provided outcomes that were similar to those of non-weight-bearing cast immobilization in non-operative management of acute Achilles tendon ruptures.
- In an RCT comparing standard-of-care orthoses with experimental pressure-based orthoses to prevent plantar foot ulcers, the experimental orthoses outperformed the standard ones.
- A Level I study investigating surgical-site infections after foot and/or ankle surgery found an increased risk of infection associated with concomitant peripheral neuropathy, even in patients without diabetes.
This week Mady Tissenbaum retires from her role as Publisher of The Journal of Bone & Joint Surgery. Mady walked through the doors of the JBJS office 42 years ago to assume the role of a copy editor. She has been with JBJS ever since and her career responsibilities developed as the organization grew and expanded. Mady has presided over multiple important changes at JBJS: the move to Needham with the purchase of our building when we outgrew the shared space with The New England Journal of Medicine, the transition from paper and typewriter manuscripts and paper review processes to electronic submission and review, the launch of The Journal online at jbjs.org, and the branching out of our offerings to include JBJS Case Connector, JBJS Essential Surgical Techniques and JBJS Reviews.
Mady has literally “done it all” at JBJS. She has trained and collaborated with 6 Editors and attended over 60 Trustee meetings. She has led countless staff meetings and presented at a similar number of Editorial Board meetings. She has run the HR services, done all the contracting for purchased services and knows every stage of development of our complex IT backbone.
In addition, she is the archivist for The Journal and has most of its history in her head. Throughout her career, she has committed herself to the legacy of quality content that JBJS is known for, as well as to the staff, authors, and readers. Her contributions have enhanced not only JBJS, but also the larger community of scholarly publishing.
We wish you Godspeed in retirement, Mady, and thank you from the bottom of our hearts for dedicating your career to JBJS and the physicians and patients it serves.
Fondly and with great respect,
Marc Swiontkowski, MD
For decades, researchers have been investigating different methods of cartilage repair, but no approach has yet risen to “gold standard” status. In the June 24, 2015 edition of JBJS Case Connector, “Case Connections” looks at three different restorative/replacement approaches to cartilage defects.
In the springboard case by Ramirez et al., a high school athlete’s full-thickness glenoid osteochondral defect was filled arthroscopically with particulated juvenile cartilage allograft (see image below).
In an earlier case report by Convery et al., the authors recommended placing additional autogenous bone beneath allografts to augment the host bed and enhance incorporation of the allograft’s osseous shell.
Welsch et al. alert surgeons to the possibility of hypertrophic cartilage opposite a defect that’s treated with a matrix-associated autologous chondrocyte transplant (MACT). And finally, Adachi et al. report on osteonecrosis of the femoral condyles that was treated with tissue-engineered cartilage combined with a hydroxyapatite scaffold enhanced with mesenchymal stem cells.
Although prospective studies with suitable control groups will be needed to prove the efficacy of these and other restorative techniques, early intervention with biologic restoration of the articular surface could eventually have a profound influence on patients with cartilage damage.
Last week, Thomson Reuters released the 2014 edition of the Journal Citation Reports (JCR). This annual report includes several journal performance metrics, the best known of which is certainly the Impact Factor. The Impact Factor measures the citation performance of journal articles over a two-year period.
Like all metrics, the Impact Factor has its strengths and weaknesses, its champions and detractors. At JBJS, we are focused on a range of metrics, including the quality of articles submitted to us for publication, author satisfaction, and direct reader feedback and engagement.
Having said that, we wish to acknowledge the painstaking work by our Editor-in-Chief, Editorial Board, reviewers, and authors who contributed to a second straight year of dramatic growth in our Impact Factor, which increased 22.5% to 5.280 (from 4.309). That’s the highest Impact Factor among the 72 orthopaedic journals included in the JCR.
We’re proud that JBJS is having a steadily increasing influence as a source of orthopaedic information. Our ultimate goal remains the same, however – to have a positive impact on surgical expertise, clinical outcomes, and patient care.
–Mady Tissenbaum, Publisher, JBJS
Surgeons in the US perform more than 700,000 knee arthroscopies annually, but a recent BMJ systematic review/meta-analysis suggests that the pain-relief efficacy of those procedures in middle aged and older adults with degenerative knee disease are inconsequential and short-lived.
In analyzing nine randomized trials that assessed the benefits of knee arthroscopy versus control treatments including exercise and sham surgery among almost 1300 patients, the Scandinavian authors found marginal improvements in pain at three and six months after surgery, but not thereafter (overall effect size of 0.14). The results were similar in subgroups with radiographically confirmed osteoarthritis.
In analyzing nine other studies (two randomized and seven observational) assessing possible harm from knee arthroscopy, authors found non-negligible rates of adverse effects, including deep vein thrombosis (4 events per 1000 surgeries), infection (2 events per 1000 surgeries), and pulmonary embolism and death (1 event each per 1000 surgeries).
The authors conclude that these findings “do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”
In an accompanying editorial, Andrew Carr, FRCS, from the UK’s Botnar Research Centre, notes that only two of the nine randomized trials analyzed to determine benefit were adequately blinded, but he basically agrees that “in robust and bias-free trials that use placebo controls, active treatment works no better than control treatment.” Considering the harm analysis the authors present, Dr. Carr concludes that “we may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests.”
OrthoBuzz readers, are we near that tipping point—or beyond it?
Orthopaedic surgeons have always been interested in limiting blood loss when it comes to major procedures. No procedures are more representative of that effort than hip and knee arthroplasty. A well-done meta-analysis by van Bodegan-Vos et al. in the June 17, 2015 JBJS looks at blood conservation through cell salvage—the perioperative suctioning, collection, concentration, and re-infusion of a patient’s own blood.
The authors report that cell salvage significantly protected patients from the need for allogeneic blood transfusions based on well-performed RCTs prior to 2010, but they found no significant effect in similar trials performed after 2010. What changed? Among other things, the surgical community adopted stricter transfusion-trigger criteria in uncomplicated cases, from a hemoglobin concentration of <10 g/dL to a hemoglobin concentration between 7 and 8 g/dL.
From my point of view, cell salvage is an example of technology that was developed to meet a clinical “standard” that was incompletely examined in prior research. There are many other clinical standards that we use in daily practice that have been inadequately evaluated; ordering blood cultures for febrile episodes and imposing BMI limits for surgery center-based procedures are just two examples.
It would certainly be preferable to examine the actual clinical validity and public health implications of these so-called standards before we develop expensive interventions, such as cell salvage, to respond to them. In that way the orthopaedic community can expand our role in meeting the goals of the Institute for Healthcare Improvement’s Triple Aim: better care for individuals, improved population health, and lower per capita health care costs.
Marc Swiontkowski, MD
JBJS Editor in Chief
Most surgeons believe that an open fracture of an extremity is an indication for antibiotic prophylaxis. However, few are familiar with the evidence to support this practice, and the optimum duration of treatment is unknown. In the June 2015 issue of JBJS Reviews, Chang et al. report the results of a systematic review of randomized controlled trials to help shed light on this question. The investigators performed a review of different antibiotic regimens, including antibiotic prophylaxis versus no prophylaxis, longer versus shorter durations of treatment, and the use of alternative drugs.
Using systematic review and meta-analysis methodology, the investigators identified 329 potentially eligible articles, of which seventeen were found to be eligible for inclusion in the analysis. Four randomized controlled trials that involved 472 patients demonstrated significantly lower rates of infection in patients who received antibiotic prophylaxis compared with those who did not receive antibiotic prophylaxis. Three studies involving 1104 patients demonstrated no difference in the infection rate when a longer duration of antibiotic prophylaxis was compared with a shorter duration (three to five days versus one day).
However, confidence in the estimates for both of these questions was low to moderate, and individual comparisons of alternate drugs yielded only low to very low confidence. The investigators concluded that the results of randomized controlled trials performed to date provide evidence that antibiotic prophylaxis reduces infection and that treatment for as short as one day is as effective as treatment for three to five days. Although the evidence warrants only low to moderate confidence, these findings provide support for the design and execution of a large, multicenter, randomized controlled trial to address the question of how antibiotics may be best used in the treatment of open extremity fractures.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
The overall rate of symptomatic lower-extremity deep vein thrombosis (DVT) following arthroscopic ACL procedures is reported to be <0.3%, and guidelines from the American College of Chest Physicians recommend against DVT prophylaxis prior to arthroscopic knee surgery, unless a patient has risk factors for blood clots. But some patients are unknowingly at high risk for clots, as a case report by Ackerman et al. in the June 10, 2105 JBJS Case Connector shows.
A 45-year-old woman presented for arthroscopic ACL reconstruction in her left knee. Unbeknownst to her or her surgeons, the patient had asymptomatic May-Thurner syndrome—an anatomic variant of the iliac blood vessels in which the right common iliac artery crosses over the left common iliac vein, compressing the vein against the lumbar spine.
Nine days after ACL surgery, the patient showed up in the ED with pain and swelling in the operative leg. Ultrasound revealed an extensive DVT extending distally from the common femoral vein. Imaging of the chest and cardiac workups were negative for heart or lung thromboembolism.
A heparin drip was started, and a vascular surgeon ordered a left-leg venograph, which revealed a large clot extending from the origin of the left common iliac vein to the insertion site of the catheter in the popliteal vein. Severe stenosis of the left common iliac vein confirmed May-Thurner syndrome (see image below).
Treatment consisted of an infusion of tissue plasminogen activator (Alteplase) directly to the clot, continued intravenous heparin, and an angioplasty with stents to open the stenosed left common iliac vein. Mechanical thrombolysis and aspiration of a residual femoral vein thrombus was accomplished with a Trellis device.
Postoperatively the patient was transitioned to therapeutic warfarin for six months and instructed to wear compression stockings. She completed her ACL physical therapy protocol uneventfully, and one year after the ACL reconstruction, the knee graft was stable and there was no evidence of post-thrombotic syndrome.
The authors remind orthopaedists that May-Thurner syndrome, which is more common in women than men, should be suspected in the presence of an extensive iliofemoral DVT. They emphasize that multimodal and aggressive treatment, in consultation with a vascular specialist, should be initiated to bust the clot and reduce the risk of post-thrombotic syndrome. Post-clot, such patients should be maintained on warfarin for a minimum of six months, and patients with stents often require lifelong aspirin therapy.
One benefit of our digital age is that it allows virtually real-time “conversations” to be published between authors of orthopaedic studies and their colleagues, without the lag time imposed by print.
Case in point is the engaging back-and-forth between James Sanders, MD (co-author of the April 16, 2014 JBJS study titled “Bracing for Idiopathic Scoliosis: How Many Patients Require Treatment to Prevent One Surgery?”) and Hans-Rudolf Weiss, an orthopaedic surgeon from Germany.
The original study found that bracing for idiopathic adolescent scoliosis substantially decreased the risk of curve progression to a surgical range—but only when patients wore the brace at least 10 hours a day. Among those “highly compliant” patients, the number needed to treat to prevent one surgery was 3. However, only 31% of the 126 subjects in the study were highly compliant. The authors also noted that current bracing indications include many curves that would not have progressed to surgical range even if the patient had not worn a brace.
In an eLetter (click on the “eLetters” tab under the article citation), Dr. Weiss stressed that patient compliance with bracing is largely influenced by the physician, but that half of the members of the Scoliosis Research Society do not believe in bracing. He additionally suggested that the findings pertain to the brace designs used in the study and may not be generalizable to other brace types. Dr. Weiss concluded that “long-term corrections can be achieved when recent bracing standards are applied.”
In a response to Dr. Weiss’s eLetter, Dr. Sanders suggested that the recent publication of the BrAIST study, which provided high-level evidence that bracing can prevent progression to a surgical range, has bolstered the ranks of bracing “believers” among orthopaedists. Despite that, Dr. Sanders points out that even strong physician proponents of bracing are “likely to have patients for whom bracing is unacceptable and their compliance poor.” That fact, he says, “makes it our imperative to develop bracing which is effective while still being both comfortable and psychosocially acceptable to patients.”