Archive | October 2015

JBJS Case Connections: Overcoming Growth-Plate Disturbances

In an ideal world, nothing would interfere with long-bone growth plates in kids and adolescents. But physes are the weakest areas of the growing skeleton and are thus vulnerable to any number of injuries and insults. The most frequent complication resulting from growth-plate disturbances is premature arrest of bone growth that can lead to alignment problems and limb-length discrepancies.

The October 28, 2015 “Case Connections” from JBJS Case Connector highlights four case reports focused on tibial and femoral growth-plate disturbances. In two of the case reports, including the springboard case by Tomatsuri et al. from the October 28, 2015 edition of JBJS Case Connector, the injuries were associated with reconstruction of a torn anterior cruciate ligament (ACL). The other two describe physeal injuries with infectious etiologies. The outcomes in all four case reports were positive because of careful and creative surgical interventions by highly skilled orthopaedists.

3-D Imaging Provides More Accurate Picture of Scoliosis Deformities

Scoliosis is a three-dimensional deformity (coronal, axial, and sagittal), so it makes sense that a 3-D imaging method for evaluating the condition and measuring the impact of surgical correction would outperform traditional two-dimensional imaging techniques. That’s exactly what Newton et al. found in their Level II diagnostic study in the October 21, 2015 edition of The Journal of Bone & Joint Surgery.

The authors analyzed 3-D and 2-D images from 120 patients with adolescent idiopathic scoliosis (AIS), before and after surgery with segmented thoracic pedicle-screw instrumentation. The mean preoperative Cobb angle on the standard 2-D view was 55° ± 10°, while on the 3-D view it was 52° ± 9° (p ≤ 0.001). The mean T5-T12 kyphosis on the 2-D view measured 18° ± 13° preoperatively and 27° ± 6° postoperatively, while the mean T5-T12 kyphosis on the 3-D view measured 6° ± 14° preoperatively and 26° ± 6° postoperatively. The difference between the 2-D and 3-D measurements of T5-T12 kyphosis strongly correlated with apical vertebral rotation.

The significant preoperative overrepresentation of the T5-T12 kyphosis on standard 2-D imaging compared with 3-D assessments led the authors to conclude that “the sagittal profile evaluated by the standard lateral view is unreliable and often results in a false sense of thoracic kyphosis.” They go on to claim that “measurement with the 3-D, segmental local vertebral approach can be a useful, surgeon-oriented method for evaluating the deformity of scoliosis as well as the correction associated with surgical treatment.”

Open Fractures – How Should We Irrigate Them?

Irrigation and debridement of open fractures have been standard practices since the late 1800s.  However, the finer details have not been agreed upon. For example, should we use higher pressures with pulsatile lavage devices?  And will adding soap to standard saline irrigation solution get better results? Answers to those two questions from lab and animal studies over the years have been limited and contradictory. The goal of the recently reported FLOW study (Fluid Lavage of Open Wounds) was to answer those questions definitively.

Initially, a pilot study with just over 100 patients suggested that using soap might yield fewer adverse events requiring a return to the OR.  Little difference was noted between high and low pressures using a pulsatile lavage device.  Most importantly, the pilot showed that a definitive study was feasible.

FLOW investigators, of which I was one, then began pursuing a multicenter, international, randomized, controlled study to evaluate the effects of irrigation pressure and solutions on open fractures. The US Department of Defense (DoD), the Canadian Institutes of Health Research, and others supported us in the definitive trial. From what we learned in the pilot study and from DoD input, we added a third arm to the pressure investigation and included gravity flow, which is essentially a bag of fluid run through quarter-inch tubing into the wound.

We collected data for five years from 2,447 patients at 41 sites worldwide and achieved a 90% 12-month follow-up.  The results demonstrated that reoperation rates for the three different pressures were similar.  But unlike the size-limited data from the pilot study, using soap in the irrigation solution resulted in a significantly higher reoperation rate than normal saline.

This second finding should convince us that saline is the irrigation solution of choice and that by avoiding soap, adverse outcomes can be diminished and costs lowered for institutions.  The discrepancy between the soap findings in the pilot data and the full study may simply reflect the need for larger numbers.  Intuitively, we might think that soap, which we use all the time for hand-washing, would be better because it helps remove debris and bacteria.  However, the FLOW findings suggest that soap may have a negative impact on soft tissues and bone, making reoperation rates significantly higher. In regard to pressures, the use of a pulsatile lavage with high or low pressures offered no apparent benefit compared to irrigation with gravity flow.  This should allow sites to avoid the cost of using pulsatile lavage devices.

Taken together, these findings should reassure institutions worldwide that do not have access to soap or pulsatile lavage devices that their wound-irrigation practices are not compromised and may indeed be the standard of care based on the FLOW data.

Kyle Jeray, MD

Greenville Health System

Vice-Chairman of Academics, Department of Orthopaedic Surgery

JBJS Associate Editor

TKA Decisions Must Align with Patient Preferences and Values

It’s a generally accepted “fact” that total knee arthroplasty (TKA) ranks among the most significant modern medical advancements. But the October 22, 2015 NEJM published the first rigorously controlled randomized study that “proves” that “fact” by comparing TKA to nonsurgical management.

One hundred patients with moderate-to-severe knee osteoarthritis were randomly assigned to undergo TKA followed by 12 weeks of rigorous nonsurgical treatment, or the nonsurgical treatment alone. Over a 12-month follow-up period, TKA was superior to nonsurgical treatment in terms of pain relief and functional improvement, but it was also associated with a higher number of serious adverse events, including deep-vein thrombosis and infection.

The study authors concluded that “the benefits and harms of the respective treatments underscore the importance of considering patients’ preferences and values during shared decision making about treatment for moderate-to-severe knee osteoarthritis.” JBJS Deputy Editor Jeffrey Katz, MD concurred with that conclusion in an accompanying editorial: “Treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes,” he wrote. “Each patient must weigh these considerations and make the decision that best suits his or her values.”

Lumbar Spine Surgery Helps Parkinson Patients

Despite a higher rate of complications than in the general population, overall outcomes of lumbar spine surgery in patients with mild to moderate Parkinson disease are favorable, with significant improvements in spine-related pain and function. So concludes a study by Schroeder et al. in the October 21, 2015 Journal of Bone & Joint Surgery. Improvements were seen in surgeries with and without instrumentation over an average follow-up of more than two years.

Among the 20 of 96 patients in the study who required revision surgery, risk factors for revision included a Parkinson disease severity of ≥3 on the modified Hoehn and Yahr scale, a history of diabetes mellitus, treatment for osteoporosis, and a combined anterior/posterior surgical approach (which was used in 22 of 63 patients who underwent instrumented fusions).

In light of these findings, Schroeder et al. recommend that, among patients who have Parkinson severity ≥3 and in those with non-insulin-dependent diabetes or severe osteoporosis, lumbar spine surgery should be done only in cases with concomitant myelopathy. They also remind surgeons that if the patient’s spine pathology is severe enough to mandate a combined anterior and posterior approach, “the risk of surgery is high.”

Acute Low Back Pain: Adding Oxycodone to Naproxen Doesn’t Help

As if on cue, a just-published study in JAMA backed up the recent AAOS statement on opioids by finding that neither the opiate oxycodone nor the muscle relaxant cyclobenzaprine (Flexeril) is a helpful adjunct to naproxen for acute, nontraumatic, nonradicular low back pain.

The study randomized 323 emergency-department (ED) patients presenting with low back pain to receive a 10-day course of naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/acetaminophen. The improvement in scores on the Roland-Morris Disability Questionnaire between the time of ED discharge and one week later was similar in all three groups. This finding led Journal Watch Emergency Medicine Associate Editor Daniel Pallin, MD to comment that “prescribing opioids for a condition that evidence-based consensus guidelines warn against can lead to abuse and addiction.”

JBJS Editor’s Choice—Clinical Practice Guidelines: What Good Are They?

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Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.

The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.

The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs.  Waiting longer to make judgments about the impact of CPGs seems appropriate.

There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.

So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

What’s New in Hip Replacement: Level I and II Studies

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 September 16, 2015 Specialty Update on hip replacement:

Transfusion and Blood Management

–Studies continue to demonstrate that tranexamic acid decreases the need for transfusion when used either intravenously or topically.

–The routine use of a drain following total hip replacement, even when used for reinfusion of shed blood, provides little to no benefit and does not decrease the risk of transfusion.1

Preoperative Patient Teaching

–A Cochrane review concluded that preoperative teaching resulted in only modest improvements in quality of life, pain scores, anxiety, and function. Patients with depression, anxiety, and unrealistic expectations might receive the most benefit from these interventions.2

Surgical Approaches

–A meta-analysis demonstrated short-term superiority of the direct anterior approach over the posterior approach, but the authors concluded there was insufficient evidence of clear long-term superiority of either approach.3

–A study that reviewed the results of two academic surgeons who exclusively used either the direct anterior approach or a miniposterior approach found no systematic advantage to either approach in terms of surgical time, pain, or function. This suggests that factors other than surgical approach may be more important in influencing early recovery after hip replacement.4

Surgical Fixation

–A randomized trial comparing survivorship in four cemented femoral stem designs concluded that, in the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups, a polished surface conferred improved survivorship.5

–A multivariate registry-based meta-analysis found that, in patients who were 75 years or older, uncemented fixation had a significantly higher risk of revision than hybrid fixation.

Bearing Materials

— A multivariate registry-based meta-analysis concluded that use of ceramic implants with a smaller head size in cementless hip arthroplasty was associated with a higher risk of revision, compared with metal-on-highly cross-linked polyethylene and >28-mm ceramic-on-ceramic implants.

–A registry-based cohort study comparing revision rates in metal-on-conventional polyethylene bearings with metal-on-highly cross-linked polyethylene bearings found a rate over seven years of 5.4% for the conventional polyethylene bearing versus 2.8% for the highly cross-linked bearing.6

–A randomized study comparing metal-ion levels five years after metal-on-metal and metal-on-polyethylene hip replacements found significantly lower cobalt and chromium levels in the metal-on-polyethylene group.

–A multivariate meta-analysis comparing the risk of revision for metal-on-conventional and metal-on-highly cross-linked polyethylene implants in patients 45 to 64 year old did not find a difference between the two groups.

–A meta-analysis comparing ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene found no differences in medium-term survivorship.7

References

  1. Thomassen BJ,  den Hollander PH,  Kaptijn HH,  Nelissen RG, Pilot P. Autologous wound drains have no effect on allogeneic blood transfusions in primary total hip and knee replacement: a three-arm randomised trial. Bone Joint J. 2014 Jun;96-B(6):765-71.
  2. McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev.2014;5:CD003526. Epub 2014 May 13.
  3. Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015Mar;30(3):419-34. Epub 2014 Oct 22.
  4. Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MWDirect anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res. 2015 Feb;473(2):623-31.
  5. Hutt J, Hazlerigg A, Aneel A, Epie G, Dabis H, Twyman R, Cobb A. The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs. Int Orthop. 2014 Jun;38(6):1131-7. Epub 2014 Jan 29.
  6. Paxton EW, Inacio MC, Namba RS, Love R, Kurtz SM. Metal-on-conventional polyethylene total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry. Clin Orthop Relat Res. 2015 Mar;473(3):1011-21.
  7. Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, Trousdale RT.There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.

AAOS Issues Statement on Opioids in Orthopaedics

The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.

Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:

  • Opioid-prescription policies at the practice level that
    • set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
    • limit opioid prescription sizes to only the amount of medication expected to be used,
    • strictly limit prescriptions for extended-release opioids, and
    • restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
  • Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
  • Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
  • An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
  • CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.

Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”

Synovial Aspirates to Differentiate Septic vs Aseptic TKA Failures

When diagnosing loose components after total knee arthroplasty (TKA), orthopaedists often turn to synovial-fluid analysis to help them differentiate between septic and aseptic causes. But how useful are such analyses clinically? Although that was not the primary research question in the October 7, 2015 JBJS article by  Chalmers et al., their findings shed light on the utility of synovial white blood-cell (WBC) counts in differentiating  aseptic  from septic loosening.

When the authors compared synovial-fluid characteristics among patients with periprosthetic infections to those among patients with various modes of aseptic failure (including extensor mechanism failure, component malposition, polyethylene wear, and periprosthetic fracture), they concluded that “to maximize the diagnostic accuracy of synovial aspiration, different [WBC] cutoffs may need to be employed depending on the clinical scenario and the alternative diagnosis being considered.”

For example, Chalmers et al. found that if there was radiographic evidence of component malposition at the same time a surgeon suspected periprosthetic infection, the optimal WBC cutoff would be 2104 cells/µL (sensitivity=95%; specificity=100%).  But if a patient presented with a periprosthetic fracture and  the surgeon suspected that the fracture may have occurred as a consequence of septic loosening, the optimal WBC cutoff would be 4697 cells/µL (sensitivity=89%; specificity=100%). Meanwhile, the current AAOS Clinical Practice Guideline cutoff for chronic periprosthetic infection is 1700 cells/µL.

The variability in these findings led the authors to conclude that “the optimal diagnosis of periprosthetic infection on the basis of synovial aspiration results may need to utilize different cutoff values depending on the alternative mode of failure being considered.”