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 August 19, 2015 Specialty Update on limb lengthening and deformity correction:
Pediatric Disorders and Trauma
–A modified guided-growth technique for insertion of tension-band plates decreased operative time, radiation exposure, and incision size.1
–Two meta-analyses concluded that, although oral or intravenous bisphosphonates in children with osteogenesis imperfecta increased bone mineral density, evidence of reduction in fracture rates was inconclusive.2, 3
–A systematic review of 40 studies on surgical management of posttraumatic cubitus varus in children noted an overall complication rate of 14.5%, with no single technique being substantially safer or more effective.4
Lower-Limb Trauma/Reconstruction in Adults
–A prospective randomized study on the surgical treatment of complex knee dislocations with ligament reconstruction found a significantly lower risk of delayed ligament failure with adjunctive hinged external fixation compared with a hinged knee brace.
–A prospective randomized study comparing biplanar external fixation with reamed interlocking intramedullary nailing for treating open tibial shaft fractures found similar healing rates and functional outcomes one year postoperatively.5
–Patients with extra-articular distal tibial fractures treated with circular external fixators had earlier weight-bearing and superior function compared with those managed with plate fixation.6
–A randomized controlled trial of patients with medial compartment knee osteoarthritis reported similar radiographic outcomes six years postoperatively among those who had opening-wedge high tibial osteotomy compared with those who had undergone closing-wedge high tibial osteotomy. The closing-wedge group had fewer complications but greater prevalence of conversion to total knee arthroplasty.
Foot and Ankle Reconstruction
–A multicenter prospective study comparing ankle arthroplasty with ankle arthrodesis noted similar patient-reported outcomes, although revision rates and major complications were higher following ankle replacement.
Managing Postoperative Complications
–A comparative study noted a lower prevalence of pin-site infections with the use of chlorhexidine (9.2%) compared with povidone-iodine (27.9%) following external fixation.7
–A randomized study revealed a 27% reduction in external fixation time with the use of low-intensity pulsed ultrasound for tibial osteoplasty.8
–A randomized trial in patients undergoing bilateral tibial lengthening showed no improvement in postoperative pain or ankle-joint mobility following botulinum toxin A injection in the calf muscle.9
New Tools and Techniques
–In a matched-pair study, patients undergoing femoral lengthening using a motorized intramedullary nail showed better consolidation indices, better knee mobility, and decreased complication rates compared with conventional external fixation.10
- MasquijoJJ, Lanfranchi L, Torres-Gomez A, Allende V. Guided growth with the tension band plate construct: a prospective comparison of 2 methods of implant placement. J Pediatr Orthop. 2015 Apr-May;35(3):e20
- Dwan K, Phillipi CA, Steiner RD, Basel D. Bisphosphonate therapy for osteogenesis imperfecta. Cochrane Database Syst Rev. 2014;7:CD005088. Epub 2014 Jul 23
- Hald JD, Evangelou E, Langdahl BL, Ralston SH. Bisphosphonates for the prevention of fractures in osteogenesis imperfecta: meta-analysis of placebo-controlled trials. J Bone Miner Res.2014 Nov 18
- Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Joint J. 2014May;96-B(5):691-700
- Rodrigues FL, de Abreu LC, Valenti VE, Valente AL, da Costa Pereira Cestari R,Pohl PH, Rodrigues LM. Bone tissue repair in patients with open diaphyseal tibial fracture treated with biplanar external fixation or reamed locked intramedullary nailing. Injury. 2014 Nov;45(Suppl 5):S32-5
- Fadel M, Ahmed MA, Al-Dars AM, Maabed MA, Shawki H. Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia. Int Orthop. 2015 Mar;39(3):513-9. Epub 2014 Dec 5
- Cam R, Demir Korkmaz F, Oner Şavk S. Effects of two different solutions used in pin site care on the development of infection. Acta Orthop Traumatol Turc.2014;48(1):80-5
- Salem KH, Schmelz A. Low-intensity pulsed ultrasound shortens the treatment time in tibial distraction osteogenesis. Int Orthop. 2014 Jul;38(7):1477-82. Epub 2014 Jan 7
- Lee DH, Ryu KJ, Shin DE, Kim HW. Botulinum toxin A does not decrease calf pain or improve ROM during limb lengthening: a randomized trial. Clin Orthop Relat Res.2014 Dec;472(12):3835-41
- Horn J, Grimsrud Ø, Dagsgard AH, Huhnstock S, Steen H. Femoral lengthening with a motorized intramedullary nail. Acta Orthop. 2015 Apr;86(2):248-56. Epub 2014 Sep 5
Infections of the spine are particularly challenging to orthopaedists because they often present emergently, can be difficult to diagnose precisely, and can have catastrophic or fatal outcomes if not treated effectively.The September 23, 2015 “Case Connections” from JBJS Case Connector discusses five cases of rare but serious spinal infections.
The “Case Connections” springboards from a September 9, 2015 JBJS Case Connector case report by Rosinsky et al. that describes a sixty-five-year-old man who presented with fever and intractable lumbar pain that radiated to his right leg. In this case, a methicillin-susceptible Staphylococcus aureus (MSSA) infection had formed a large lobulated epidural abscess at L4-S1, with paraspinal muscle and intradural extension. One year after an L3-S1 laminectomy and two follow-up surgeries to treat hematomas and repair dural perforations, the patient was neurologically intact and walking independently.
The Rosinsky et al. case and the three other relevant “connections” from the JBJS Case Connector archive emphasize that prompt, definitive diagnosis and treatment of spinal infections–and enlisting the expertise of infectious-disease specialists–can lead to positive outcomes, while delay and clinical confusion can end catastrophically or fatally.
The goals of orthopaedic surgery for children with cerebral palsy (CP) include pain and spasticity reduction and improvements in hygiene and functional mobility. A multicenter study by Mulcahey et al. in the September 16, 2015 JBJS found that when assessing changes in lower-extremity mobility derived from orthopaedic surgery among 255 CP patients, computerized adaptive testing (CAT) was more sensitive than other commonly used instruments. Specifically, improvements in function detected by the CAT at 12 and 24 months following surgery were greater than the changes detected by the relevant domains of the oft-administered Pediatric Outcomes Data Collection Instrument (PODCI).
Interestingly, neither of those two instruments, nor the timed “up & go” test, performed well with patients at level II of the Gross Motor Function Classification System. Furthermore, the authors note that CAT results are based on parent reports and therefore provide perceived outcomes rather than direct measures. Nevertheless, this study yields sound evidence that the benefits of orthopaedic surgery in people with CP heretofore measured with less sensitive instruments are in fact substantial.
In less than a week from this posting, on October 1, 2015, ICD-10 diagnosis codes will debut. OrthoBuzz already reported on the 12-month leniency policy announced by the Centers for Medicare and Medicaid Services (CMS). In addition, during the home-stretch to the ICD-10 launch, CMS has published an online series of “cheat sheets” to help providers select at least the first few correct digits for the new codes. The guidance is primarily for family practitioners, but there are sections for back and neck pain and joint and limb pain that orthopaedists might find useful.
Keep in mind that private insurers are not obliged to follow CMS’s leniency lead in this area, although according to a Medscape.com article, Aetna, Humana, and Anthem have announced that they will. UnitedHealthcare is reportedly still mulling the issue, and Medicaid policies regarding how precise ICD-10 codes need to be will vary from state to state.
After October 1, please share your early ICD-10 experiences with OrthoBuzz by clicking on the “leave a comment” button in the box next to the title of this post. And good luck!
The September 16, 2015 JBJS study by Robinson et al. offers clear proof that many of our patients are sensitive to price when it comes to choosing where to go for arthroscopic surgery of the knee or shoulder. This phenomenon began at least a decade ago when employers began shifting the cost burden of health care coverage onto their employees. The findings from Robinson et al. confirm the increasing strength of this effect.
The authors analyzed administrative data from the California Public Employees’ Retirement System (CalPERS) to evaluate the impact of so-called “reference-based benefits” on patient choice for the setting of arthroscopy—hospital-based outpatient departments or freestanding ambulatory surgery centers (ASCs). Reference-based benefits require patients to pay the cost differential between an insurer-established “contribution limit” and the actual price charged by a facility.
Within two years of shifting to reference-based benefits, CalPERS-covered patients increased their utilization of ASCs by 14.3% for knee arthroscopy and by 9.9% for shoulder arthroscopy, with corresponding decreases in the use of hospital-based facilities. Meanwhile, CalPERS reduced overall spending on these procedures by 13%, and there were no significant before-and-after differences in 90-day complication rates.
These findings lead one to ask what added benefits patients receive from hospital-based outpatient surgery — Is it a safer environment or more convenient? Are the results more predictable? I think not, and on that basis the added charges are not justified.
Now that Robinson et al. have provided us with hard data on the impact of surgical-setting charges on patient behavior, we need to think about providing additional information that our patients would find helpful. We should, for example, move forward with increasing transparency on surgery fees and charges for outpatient visits, imaging, and durable medical goods. The time is right for us to do our part in eliminating this “black box” aspect of orthopaedic care.
At the same time, as commentators Kern Singh and Junyoung Ahn note, because payers will continue to define value according to their criteria, “orthopaedic surgeons should increase their involvement in this process to ensure the balance between outcome benefits and associated costs.”
Marc Swiontkowski, MD
Perioperative anticoagulation for patients undergoing orthopaedic surgery remains a challenge. Currently, there is insufficient evidence to provide definitive recommendations for care. Recent estimates suggest that, in the U.S. alone, there are over two million patients with atrial fibrillation who receive warfarin each year. Moreover, >100,000 heart valve replacements are performed annually.
In the September 2015 issue of JBJS Reviews, Dundon et al. review current recommendations for perioperative management of patients on existing anticoagulation therapy. They note that cessation of warfarin is based on risk stratification for thromboembolic events and bleeding risk, with cessation and bridging therapy being recommended if patients are at high risk for thromboembolic events or bleeding. On the basis of their assessment of published reports, they recommend that warfarin should be withdrawn and that bridging therapy should be instituted five days prior to surgery. Cessation and regular dosing should be resumed twelve to twenty-four hours after the operation.
However, the issue of perioperative bridging is currently under debate. The authors of this article could find no double-blind, randomized, controlled trials in which patients undergoing vitamin-K antagonist therapy who had received bridging with low-molecular-weight heparin or unfractionated heparin were compared with patients undergoing vitamin-K antagonist therapy who had received no bridging therapy. Bridging therapy with therapeutic-dose intravenous unfractionated heparin should be stopped four to six hours before surgery, but patients receiving therapeutic-dose subcutaneous low-molecular-weight heparin should take the last dose approximately twenty-four hours prior to surgery.
The authors recommended that patients in high cerebrovascular and cardiovascular risk groups should maintain aspirin with bridging therapy and may also maintain clopidogrel in emergencies as long as they are not undergoing a high-risk procedure. For patients who take rivaroxaban or dabigatran, emergency surgery is permissible as long as levels of the drug are ≤30 ng/mL at the time of admission.
These recommendations are based on careful and critical analyses of available data; however, as noted above, there are no critical evidence-based studies in the area of perioperative management of anticoagulation in patients who are undergoing orthopaedic surgery. The concepts and ideas presented in this article should be considered as recommendations at best.
Thomas Einhorn, Editor
A late-August headline on MedPage Today ominously read, “MI Risk Soars After Joint Replacement.” The article cited a recent Arthritis & Rheumatology study that found a more than 8-fold increase in risk of myocardial infarction (MI) for one month after knee replacement and a more than 4-fold increased risk during the month after hip replacement, all compared with equal numbers of matched controls who did not have joint replacement surgery.
A look at the absolute risk instead of the relative risk, however, reveals a different and less scary story. For example, among the 13,849 patients who underwent knee replacement, 306 (2.2%) had a heart attack within the first month after surgery. The rate of heart attacks among the equal number of people who did not have a knee replaced was 2.0%. Also, the increased MI risk seen during the first month after surgery steadily declined with increasing length of follow-up to the point where it became statistically insignificant at 6 months after surgery.
There’s little doubt that major orthopaedic surgery can stress the heart, but the many long-term cardiovascular benefits of joint arthroplasty, including advantages from increased physical activity and decreased use of NSAIDs, seem to outweigh the short-term risk of a heart attack.
We know that more than 1 million total hip and total knee replacements are performed each year in the US. But how many people are actually walking around right now with such prostheses?
That’s the question Kremers et al. answer in the September 2, 2015 edition of The Journal of Bone & Joint Surgery. Using the so-called “counting method” to combine historical incidence data, these Mayo Clinic authors concluded that about 7 million US residents (slightly more than 2% ) were living with a hip or knee replacement in 2010.
Prevalence of hip replacement was 0.83%, while that of knee replacement was 1.52%. Not surprisingly, prevalence increased with age (5.26% for total hip and 10.38% for total knee at 80 years of age), but the authors also found a shift toward younger people having the procedure.
These prevalence stats for hip and knee replacement are similar to those for stroke (6.8 million) and myocardial infarction (7.6 million), underscoring just how common these orthopaedic procedures are. Even in the unlikely event that the annual incidence of these joint replacements remains steady rather than rises, the authors estimate that 11 million people will be living with artificial hips or knees in 2030.
According to Kremers et al., among the many implications of these findings is “a need for the medical profession and the policy makers to recognize and address the lifelong needs of this population,” including the development of evidence-based protocols for follow-up care and radiographic assessments.
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.
George Phalen’s article, “The Carpal-Tunnel Syndrome,” was published in The Journal of Bone and Joint Surgery in 1966. I feel some kinship with Phalen because he and I both grew up in Illinois, and we both obtained medical degrees from Northwestern University. (Phalen graduated from Northwestern in 1937, 48 years before me, which makes me feel young.) Dr. Phalen finished his residency at the Mayo Clinic and was a founding member (and later a president) of the American Society for Surgery of the Hand.
Several characteristics make “The Carpal-Tunnel Syndrome” a classic. First, Phalen’s article stands out as the definitive description of a common condition that, while previously noted by others, had never been studied so thoroughly or documented so completely. Phalen’s paper, which reviewed a 17-year experience of diagnosing and treating 654 hands at the Cleveland Clinic, was the pivotal scientific text that identified carpal tunnel syndrome as the most common peripheral compression neuropathy and a highly treatable orthopaedic condition. Moreover, no other article written about carpal tunnel syndrome in the past 50 years has matched Phalen’s paper with respect to both breadth and depth of knowledge.
Phalen’s article is also a classic when considered as medical literature. It is written in a way that makes critical points of anatomy, diagnostic evaluation, treatment options, and surgical management easy to remember. Although the article is 17 pages long, the content and organization are so well presented that the information flows naturally and is not burdensome to absorb. Packed with clinical and anatomical pearls, this paper is like an antique chair built by an old-school craftsman. It retains its comfort and rock-solid function even after decades of use because of the master-carpenter’s skill. This 1966 article makes me think, “They don’t often build ‘em like this anymore.”
But perhaps the most compelling “classic” feature of Phalen’s article is its lasting insights. Everything Phalen presented about carpal tunnel syndrome holds true 50 years later. This includes his descriptions of the anatomical, epidemiologic, histologic, and clinical features of carpal tunnel syndrome and his emphasis that careful history-taking and physical examination are by the far the most efficient ways to evaluate patients. He also notes the limitations of electrical testing (see related OrthoBuzz item) and presents a variety of surgical-technique tips that are still relevant today.
What is also amazing is Phalen’s observation that carpal tunnel syndrome is not truly caused by any occupation, but may be only temporarily worsened by repetitive movements. Despite subsequent decades of controversy on this subject, it is becoming clearer that, even on this point, Phalen had it right all along.
“The Carpal-Tunnel Syndrome” is a brilliant contribution to orthopaedic and hand surgery. Its detailed comprehensiveness and bulls-eye accuracy are complemented by the artful way the article is constructed and worded. Anyone treating carpal tunnel syndrome today should read this article, because a half-century later, it is still the best source of information on the subject.
Leon S. Benson, MD
JBJS Associate Editor