Archive | October 2015

“Key Procedures” Videos Debut on JBJS Essential Surgical Techniques

On Wednesday, October 14, JBJS Essential Surgical Techniques launched “Key Procedures.” These new, all-video articles feature detailed demonstrations of how to perform core orthopaedic procedures.

At an average 10-15 minutes in length, “Key Procedures” videos are succinct, to-the-point resources to help orthopaedists prepare for surgery. Whether you want to review instruments or implants you may need, learn updated techniques for core procedures, or just get a quick refresher on a procedure you haven’t done recently, these videos are available online anytime you need them. Their standardized format makes for easy viewing and navigating.

All “Key Procedures” videos are based on clinical studies that have been previously published or accepted for publication in a peer-reviewed journal, and they are therefore supported by verified outcomes. Orthopaedists can expect the same high quality, peer-reviewed content from “Key Procedures” videos that they’ve come to expect from JBJS for the last 126 years.

Released on the second Wednesday of each month, ”Key Procedures” videos provide step-by-step demonstrations of orthopaedic interventions such as meniscal repair, forearm fracture reduction, direct anterior total hip arthroplasty, lumbar microdiscectomy, and fasciotomy for compartment syndrome.

JBJS Essential Surgical Techniques is offering free access to “Key Procedures” videos for the first 6 months. Starting in March 2016, these videos can be viewed only by JBJS Essential Surgical Techniques subscribers.

Click here to learn more about “Key Procedures.”

Click here to view the inaugural “Key Procedures” video – Mensical Root Repairs.

JBJS Reviews Editor’s Choice–Syndesmotic Injuries of the Ankle

Syndesmotic injuries of the ankle, with or without malleolar ankle fractures, are common. Studies have found that up to 40% of all athletic injuries are ankle sprains and that 5% to 10% of those involve disruption of the tibiofibular syndesmosis. However, despite the frequent occurrence of this injury and related injuries, the best treatment of syndesmotic ankle injuries remains unresolved.

In the October 2015 issue of JBJS Reviews, Jones et al. describe ankle syndesmotic injuries, noting that the normal syndesmosis widening can be up to 1.5 mm, that the syndesmosis helps to prevent excessive fibular motion during locomotion, that clinical examination to diagnose syndesmotic injury is frequently inaccurate, and that initial injury and intraoperative stress radiographs help to confirm the diagnosis. The authors note that effective treatment requires accurate reduction and stable fixation in order to allow the syndesmotic ankle ligament to heal and also to limit syndesmotic motion. This effective treatment provides the best chance for the restoration of stable ankle mechanics. Nonoperative treatment of isolated injuries is appropriate in most cases. However, the timing of weight-bearing remains controversial and the timing of and indications for fixation removal after operative treatment are also unresolved.

After an extensive review and discussion of diagnostic and treatment options, this Critical Analysis Review article provides the following recommendations for ankle syndesmotic injury. There is good evidence that ankle syndesmotic reduction and fixation provides the best results. Similarly, there is good evidence that screw fixation can be achieved with engagement of three or four cortices. There is fair evidence that screw fixation can be metallic or bioabsorbable and that screw fixation and suture button fixation have similar outcomes. There is also fair evidence that syndesmotic injuries with associated malleolar fractures have the worst outcomes. However, there is poor evidence that transsyndesmotic and suprasyndesmotic fixation have similar results. There is also poor evidence that screw removal should be performed after three months.

These recommendations are based on extensive review and analysis and should be helpful in aiding in the treatment of syndesmotic ankle injuries.

Thomas A. Einhorn, Editor

JBJS Reviews

JBJS Classics: Harrington Ushered in Modern Spine Surgery in 1962


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 JBJS Classic Treatment of Scoliosis: Correction and Internal Fixation by Spinal Instrumentation by Paul R. Harrington describes 15 years of investigation, beginning in 1947, soon after Dr. Harrington completed his residency in Kansas City and headed an Army orthopaedic unit during World War II. The importance of this paper can’t be overstated. With this description of instrumentation that improved deformity outcomes, Harrington ushered in modern spine surgery.  It was also one of the rare early examples of orthopaedic clinical science funded by a national grant.

The need for this daring, revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Polio patients comprised 75% of the first series described in this paper.

This comprehensive study combines theory, basic science, surgical techniques, and outcomes. With it, Harrington started the still-continuing dialogue about indications for scoliosis surgery with the comment that “clinical indications for therapy are still being worked out.” As a partial answer to the indications quandary, he introduced the Harrington factor—the number of degrees of primary curve divided by the number of vertebrae in the primary curve. This calculation continues to be used (renamed) in some current research into risks of curve correction, while debate continues about other indications such as progression, pain, and pulmonary issues.

The technique of spinal instrumentation is extensively described in this landmark article. Noteworthy is Harrington’s gradual embrace of the need for fusion and well-molded body cast immobilization, both of which he credits with improved results. (Initially Harrington had hoped to avoid fusion in many cases.) Although “instrumentation” today is nearly synonymous with “fusion,” some of our most promising ideas in deformity correction now involve instrumentation without fusion.

Also impressive is the respect with which Harrington treated the spinal cord and dura. He describes careful insertion of the hooks and recommends against downward hooks above L2, where the conus ends. This paper reminds us that we should always pursue the lowest-risk approach to instrumentation that will serve our patients. Dr. Harrington was also cognizant of the importance of blood loss, and meticulously measured it by stage of surgery. He showed that most blood loss occurred during subperiosteal dissection, a fact that we still recognize today.

Harrington’s description of selective thoracic fusion was illustrated radiographically in Figure 7, which shows a dramatic result where a 55° unfused lumbar curve declined to 18° after correction of a larger thoracic curve. This concept was further developed by Moe, King, Lenke and others, but the idea of spontaneous correction of lumbar curves started with the power of Harrington’s instrumentation.

The benefits of our more “modern” instrumentation are evident when reading the recommended aftercare in Harrington’s paper: a 16-day hospital stay, 8 weeks of bed rest, and a Risser localizer cast for 3 to 5 months, only to find out whether the patient might need reoperation for instrumentation problems or pseudarthrosis.

A modern journal editor might have expended some red ink on Dr. Harrington’s paper. The organization was less formal than many scientific papers today, but this may reflect the multiple simultaneous investigations and changes that took place during this decade-plus of revolutionary work. Dr. Harrington emphasizes that the results improved with each iteration of the procedure and device, which underwent more than three dozen design modifications.

Details on the curve sizes were not given, but we now recognize that curve size does not correlate linearly with clinical parameters.  While Harrington does not describe the contributions of others who may have been involved in this work, neither does he use the eponymous term (“Harrington instrumentation”) that others attached to his spinal fixation device. While remarkable in its prescience, this paper did not anticipate the problems of distraction instrumentation in the lumbar spine, later characterized as Flatback Syndrome. It also did not elaborate on the need for differing mechanics in kyphoscoliosis or Scheuermann kyphosis.

Nevertheless, in this single article, Dr. Harrington laid the groundwork for three major themes that orthopaedists have further developed:

  • The safety and benefits of metal fixation in spine surgery
  • The use of growth guidance in patients < 10 years old
  • The idea of selective thoracic fusion for double curves

Each of these ideas has generated hundreds of additional studies and papers to get us to modern practice. Just as current hip arthroplasty techniques represent incremental improvements on the monumental contribution of Charnley, current techniques in scoliosis surgery, especially of the thoracic spine, are but stepwise improvements on Harrington’s classic work.

Paul Sponseller, MD, JBJS Deputy Editor for Pediatrics

Marc Asher, MD, Professor Emeritus, Department of Orthopaedic Surgery, University of Kansas Medical Center

History of Diabetes Predicts Symptom Recurrence after Steroid Injection for CTS

Among a prospectively enrolled group of 49 patients (54 wrists) with mild or moderate carpal tunnel syndrome (CTS) who received a single corticosteroid injection, 79% experienced symptom relief at six weeks. Reporting in the October 7, 2015 edition of The Journal of Bone & Joint Surgery, Blazar et al. found that the rate of freedom from symptom recurrence in this cohort was 53% at six months and 31% at one year after injection. During the study period, 19 wrists underwent surgical carpal tunnel release at a median time of 181 days post-injection.

Diabetic patients in the study (13% of the wrists enrolled) were at a 2.6-fold greater risk of reporting recurring symptoms within one year of follow-up. In a univariable analysis, a 1-point increase in the baseline Boston Carpal Tunnel Questionnaire symptom score increased the risk of patients reporting post-injection symptoms by 5%, but that association became nonsignificant during multivariable analysis. Pre-injection symptom duration, patient age, and pre-injection electrophysiologic grade did not predict either symptom recurrence or subsequent intervention.

Blazar et al. add that their exclusion of people with normal electromyography results and those with severe carpal tunnel syndrome created a rather homogenous study population. Thus, they say, “these results may not be generalizable to all patients who present with clinical signs or symptoms of carpal tunnel syndrome.” Still, the findings should help orthopaedists counsel patients with CTS about the results they might expect from a single corticosteroid injection.

JBJS Editor’s Choice—Achieving Incremental Progress in Spinal Deformity Correction

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Orthopaedic surgical procedures to correct axial and appendicular skeletal deformities are usually dependent upon fixation devices, either external or internal or both. These devices are often developed through close collaboration with engineers who are generally employed by major manufacturing companies. After the devices successfully clear rigorous bench, in-vitro, and in-vivo testing, the standard initial presentation of clinical results is a case series.

All too often the initial report of results comes from a co-developer of the device, with inherent selection and detection bias that constitute what most readers would consider a conflict of interest. McCarthy and McCullough’s case series on five-year results with Shilla growth guidance in 33 children with early-onset scoliosis in the October 7, 2015 JBJS is an exception to that rule. The authors report every conceivable major and minor adverse event without holding back any negative information. They categorize complications as infection secondary to wound breakdown, spinal alignment issues, and implant issues. The overall complication rate was 73%, a rate that is not surprising given the fact that the device under study is designed to maintain correction of spinal deformity in growing children.

Thankfully, the authors reported no neurologic complications. Also on the positive side, they found that spinal curves averaging 69° preoperatively averaged 38.4° at the most recent follow-up or prior to definitive spinal instrumentation. McCarthy and McCullough also calculated a 73% reduction in the number of surgical procedures among their cohort, relative to what would be necessary to treat the same population with distraction methods every six months.

I applaud the authors for comprehensively reporting the results of correction of spinal deformity in this difficult clinical situation with high accuracy and strict definitions of major and minor events. This is how we will make advances in correcting deformity for skeletally mature and immature patients—with innovation, incremental improvement, and the widespread sharing of adverse events with the orthopaedic community. Armed with the information from this study, we must now see what the number and severity of complications look like when the broader community of orthopaedic surgeons applies these devices.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

Increased Calcium Intake Neither Boosts BMD nor Reduces Fracture Risk

In two separate studies published recently in the BMJ, New Zealand researchers concluded that increased calcium intake, through diet or supplements, is unlikely to have clinically meaningful effects on bone density or fracture prevention. The findings call into question recommendations from most health care professionals for daily calcium intake of at least 1,000 to 1,200 mg in older adults.

The first study reviewed 59 randomized controlled trials (nearly 14,000 patients total) that examined the association between bone mineral density (BMD) and either dietary or supplemental sources of calcium. Increases in BMD ranged from only 0.6% to 1.8% with increased calcium intake, regardless of the source and whether calcium was taken with vitamin D. The authors concluded that these small BMD effects were “unlikely to translate into clinically meaningful reductions in fractures.”

The second study reviewed 28 randomized trials and 44 observational studies (more than 58.000 patients total) that examined the relationship between increased calcium intake and fracture prevention among people older than 50 years. The analysis found that calcium supplements have “small inconsistent benefits on fracture prevention” but that overall “there is currently no evidence that increasing calcium intake prevents fractures.”

What do you make of these findings? Please comment by clicking on the “Leave a comment” button in the box next to the title.

Time-to-Drive after TKA?

There are currently no standards or regulations governing when it’s safe to drive after a knee replacement. But researchers reporting in the American Journal of Physical Medicine & Rehabilitation found that patients with right-knee replacements using an automatic-transmission driving simulator had 30% slower braking times eight days after surgery compared with presurgery measurements.

Braking times were significantly reduced in the right-knee group for six weeks and reached preoperative levels at 12 weeks postsurgery. Braking time was only 2% slower after left-knee replacements, but braking force, a crucial factor in emergency stopping, decreased by 25% to 35% in both groups during the week after surgery.

The authors conclude that, while “categorical statements cannot be provided,” these automatic-transmission findings suggest that “right TKA patients may resume driving six weeks postoperatively.” However, even the presurgery measures of braking time and force that these researchers used may not represent “normal” values because severe osteoarthritis can impair driving skills. And the findings have no bearing on TKA patients who drive manual-transmission cars with clutch pedals.