Reducing the Risk of Ceramic Femoral-Head Fractures
JBJS Case Connector has issued a “Watch” regarding the rare but potentially catastrophic fracture of ceramic femoral heads used in hip replacements.
Ceramic hip components are often chosen for younger patients to minimize long-term wear. Ceramic femoral head fractures arise mainly from trauma; non-compatible, damaged, or contaminated femoral head/stem taper connections; or material or manufacturing defects.
Because c
eramic head fractures are more likely to occur from insults during or after implantation than from manufacturing defects, the Watch includes four “golden rules” surgeons can follow to reduce the risk of these events, including making sure that the tapers on both the head and stem are compatible in all dimensions. The Watch also emphasizes the importance of patient education, during which patients should be encouraged to promptly report any and all postsurgical irregularities.
This Watch was prompted by a case report by Pomeroy et al. in the December 23, 2015 JBJS Case Connector, and a report by Heiner and Mahoney in the October 22, 2014 JBJS Case Connector.
X-rays Miss Many Cases of Hip Osteoarthritis
It’s a good thing orthopaedists don’t rely solely on X-rays to diagnose hip osteoarthritis (OA), because an analysis of data from two large cohort studies casts doubt about the utility of radiographs in diagnosing hip OA in older patients.
Using pain localized to the groin or anterior hip or provoked by internal rotation as the clinical standard for diagnosing hip OA, the researchers compared participants’ reports of such pain with radiographic evidence. In the first cohort study (n=946), only 15.6% of hips in patients reporting frequent hip pain showed radiographic evidence of osteoarthritis. In the second study (n=4366), only 9.1% of hips in patients with frequent pain showed radiographic evidence of hip OA. Conversely, pain was not present in many hips with radiographic evidence of osteoarthritis.
These findings strongly indicate that many cases of hip arthritis would be missed if clinicians relied solely, or even largely, on radiographs. The findings also suggest that overdiagnosis of osteoarthritis would be likely if doctors relied on radiographs rather than examining patients and obtaining an appropriate history. The authors conclude that “health professionals should continue to evaluate and treat patients with hip pain suggestive of osteoarthritis despite negative radiographic findings.” This study is also a good reminder for physicians to treat patients, not imaging studies.
Naproxen Effective for Preventing HO after Hip Arthroscopy
Heterotopic ossification (HO) is a known complication of hip arthroplasty. A double-bl
ind, randomized, placebo-controlled trial by Beckmann et al. in the December 16, 2015 Journal of Bone & Joint Surgery showed that prophylaxis with naproxen dramatically reduced the prevalence of HO after hip arthroscopy, without serious medication-related side effects. These findings bolster findings from previous retrospective investigations that showed large reductions in HO prevalence among those taking nonsteroidal anti-inflammatory drugs (NSAIDs).
The patients in the study took naproxen (500 mg) or a placebo twice a day for three weeks following arthroscopic surgery for femoroacetabular impingement. After one year, the prevalence of radiographically determined HO in patients randomized to the naproxen group was 4% versus 46% in the patients randomized to the placebo group, an 11-fold difference. While the potential for serious GI and renal side effects with NSAIDs is well-documented, in this study only minor adverse reactions to study medication were reported in 42% of those taking naproxen and in 35% of those taking placebo.
Noting that the clinical consequences of HO following hip arthroscopy are “largely undetermined,” the authors still suggest a role for HO prophylaxis “because it could reduce the risk of developing symptomatic HO or requiring revision surgery for HO excision.”
In an accompanying commentary, Sverre Loken praises the authors for the well-designed study, but he cautions that “clinically relevant HO is uncommon, and this has to be weighed against the risk of serious side effects caused by NSAIDs.” He also emphasizes the observation Beckmann et al. make in the last paragraph of their study: that “the lowest dose and shortest duration of NSAID prophylaxis that still prevent HO remain to be determined.”
Psych Distress Magnifies Patient Perception of Shoulder Pain
Most studies investigating the psychosocial determinants of orthopaedic pain and
disability have focused on the spine, hand, hip, and knee. But in the December 16, 2015 JBJS, Menendez et al. looked at psychosocial associations among 139 patients presenting with shoulder complaints. Similar to findings regarding those other anatomical areas, Menendez et al. found that patient variability in perceived symptom intensity and magnitude was more strongly related to psychological distress than to a specific shoulder diagnosis, which included rotator cuff tear, impingement, osteoarthritis, and frozen shoulder.
The authors measured patient pain and disability scores upon presentation using the Shoulder Pain and Disability Index (SPADI). They then analyzed the SPADI scores in relation to sociodemographic data and patient responses to three additional validated tests measuring depression, tendencies to catastrophize, and self-efficacy. They found that disabled and retired work status, higher BMI, catastrophic thinking, and lower self-efficacy (i.e., ineffective coping strategies) were associated with greater patient-reported symptom intensity and magnitude of disability.
Interestingly, BMI was the only biological influence on pain and disability scores. Also, retirement had a negative influence on pain and disability scores, which was somewhat surprising considering that retirement often has positive effects on well-being.
The authors conclude that future research focused on the effect of psychosocial factors on postoperative pain and response to treatment might “allow surgeons to identify patients who are at risk for a treatment-refractory course.” They further surmise that “interventions to decrease catastrophic thinking and to optimize self-efficacy…before shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability.”
JBJS to Launch Elite Reviewers Program
Peer review is the basic underpinning of scientific publication, and The Journal’s reviewers are key components in our 127-year history of publishing the highest quality of evidence-based information. JBJS reviewers volunteer their time and expertise to serve the orthopaedic community and enhance the quality of care for patients.
To formally recognize the outstanding contributions of our very best reviewers, beginning in January 2016, JBJS will implement an Elite Reviewer Program. Elite Reviewers will be recognized based on measurements of their response time, quality of reviews, and reliability.
We expect that authors will benefit from the program with even higher-quality and more prompt peer review, and we hope the program inspires all of our reviewers to meet Elite Reviewer standards.
For more information about the program, read the JBJS editorial, or visit the Elite Reviewers Program page on our website.
JBJS Editor’s Choice: During Ankle Fusion, Save the Fibula!
In the December 16, 2015 edition of The Journal, Pellegrini et al. present the results from a cohort of 23 patients who had initially undergone ankle arthrodesis and then, due to decreasing function and increasing mid- and hindfoot pain, sought relief via conversion to an ankle arthroplasty. The good news is that this conversion provided meaningful clinical improvement in pain and function, with 87% survival of the implants over the mean 33-month follow-up.
One technical detail the authors recommend is prophylactic fixation of the malleoli as a concomitant procedure, noting that local osteopenia related to arthrodesis make malleoli prone to fracture during insertion of the tibial component. It is difficult to determine if these conversions were necessitated by poor surgical technique during the original arthrodesis, but I suspect in some cases they were. Also, considering the arthritic changes to the mid- and hindfoot joints related to arthrodesis, it is easy to understand that patients would benefit from the takedown of the fusion and return of some ankle motion to diminish the stress on those joints.
Reflecting on the findings from this clinical cohort series has prompted me to change my surgical technique for ankle arthrodesis. Formerly I hemi-sected the lateral malleolus and fixed it to the talus and distal tibia. Now I preserve the distal fibula, ensure removal of all cartilage in the medial and lateral gutters, add bone graft, and provide fixation with cancellous lag screws. This change in technique facilitates takedown of the fusion and conversion to ankle arthroplasty if necessary in the future. In my opinion, the clarion call now for ankle arthrodesis must be “save the fibula!”
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Orthopaedic Rehabilitation: 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 key findings from Level I and II studies cited in the November 18, 2015 Specialty Update on orthopaedic rehabilitation:
General Orthopaedics/Arthroplasty
- A prospective comparison of patients who received either skilled physical therapy (PT) or a standardized home exercise program after total knee arthroplasty (TKA) found that range of motion and functional outcome were similar in the two groups after two years, but the home program was nearly half the cost of PT.1
- A randomized trial of 198 patients who underwent TKA compared telerehabilitation with face-to-face rehab. After two months, WOMAC and KOOS scores and functional and range-of-motion tests were all noninferior for telerehabilitation.
- A randomized trial of community-dwelling elderly patients who had undergone hip fracture surgery found that an individualized home-based rehab program produced superior functional outcomes, balance, and mobility recovery when compared with a standard, non-structured home exercise program.2
- A claims-data study of 4733 people who underwent hip or knee replacement found a 29% decrease in postoperative acute service utilization among those who had preoperative PT.
- A randomized trial comparing active transcutaneous nerve stimulation (TENS), placebo TENS, and standard care during rehab for TKA found that adding either active or placebo TENS to standard care significantly reduced movement pain in the immediate postoperative period.3
- A randomized study found that in-hospital sling-based range-of-motion therapy had a clinically beneficial effect up to three months after TKA surgery in terms of passive knee flexion range of motion, compared with an in-hospital continuous passive motion protocol.4
Achilles Tendon
- A randomized trial comparing weight-bearing and non-weight-bearing for nonoperative treatment of Achilles tendon ruptures found no significant between-group differences in the Total Rupture Score or heel-rise strength.
- A systematic review and meta-analysis comprising 402 patients who had undergone surgical Achilles tendon repair found that postoperative early weight-bearing and early ankle motion exercises were associated with a lower minor complication rate and greater functional recovery when compared with conventional immobilization.5
Pediatrics
- A randomized trial comparing 12 weeks of individualized resistance training to physiotherapy without resistance training in adolescents and young adults with bilateral spastic cerebral palsy found that neither group demonstrated improvements in performance of daily physical activity.6
Motion Analysis
- A randomized trial of three methods of weight-bearing training (verbal instruction, bathroom scale training, and haptic biofeedback) found that haptic feedback was superior to the other methods at helping patients maintain weight-bearing status.7
Amputation and Prosthetics
- A systematic review of studies comparing rigid versus soft dressings after amputation determined that rigid dressings resulted in significantly shorter time from amputation to fitting of a prosthesis.8
- A randomized trial of phantom pain found that a protocol of progressive muscle relaxation, mental imagery, and phantom exercises yielded more significant reductions in the rate and intensity of phantom pain than a program of standard physical therapy.9
Low Back Pain
- Among patients with low back pain, a three-way randomized trial (standard care, standard care + extensible lumbosacral orthoses, and standard care + inextensible lumbosacral orthoses) found that inextensible lumbar orthoses led to a greater improvement in Oswestry Disability Index scores than the other two approaches.10
References
- Büker N,,Akkaya S, Akkaya N, Gökalp O, Kavlak E, Ok N, Kıter AE, Kitiş A.Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014 Oct;26(10):1531-6. Epub 2014 Oct 28.
- Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M,Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2014 May;15(5):361-8. Epub 2014 Feb 20.
- Rakel BA, Zimmerman MB, Geasland K, Embree J, Clark CR, Noiseux NO,Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain. 2014 Dec;155(12):2599-611.Epub 2014 Sep 28.
- Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014 May 9;12:68.
- Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med. 2015 Apr;43(4):1008-16. Epub 2014 May 2.
- Bania TA, Dodd KJ, Baker RJ, Graham HK, Taylor NF. The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial. Disabil Rehabil. 2015 Jun 9:1-7. [Epub ahead of print].
- Fu MC, DeLuke L, Buerba RA, Fan RE, Zheng YJ, Leslie MP, Baumgaertner MR, Grauer JN. Haptic biofeedback for improving compliance with lower-extremity partial weight bearing. Orthopedics. 2014 Nov;37(11):e993-8.
- Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. Epub 2014 Jun 6.
- Brunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, Traballesi M. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015Feb;96(2):181-7. Epub 2014 Oct 23.
- Morrisette DC, Cholewicki J, Logan S, Seif G, McGowan S. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine (Phila Pa 1976). 2014 Oct 1;39(21):1733-42.
Nauth/McKee VideoWins JBJS EST Editor’s Choice Award
To celebrate the launch of “Key Procedures” in October, JBJS Essential Surgical Techniques (EST) invited authors to enter their videos in a contest for the Editor’s Choice Video Award. We are pleased to announce that Aaron Nauth and Mic
hael D. McKee have won the inaugural Editor’s Choice Video Award for their video article “Open Reduction and Internal Fixation of Both-Bones Forearm Fractures.” This video is now live on JBJS Essential Surgical Techniques, with complimentary access.
“Key Procedures” videos offer orthopaedic surgeons succinct 15- to 20-minute, peer-reviewed videos from experts in a variety of subspecialty areas. These videos focus on performing core orthopaedic procedures such as meniscal root repairs, direct anterior hip exposure for total hip arthroplasty, and proximal tibial valgus osteotomy .
JBJS Essential Surgical Techniques is offering free access to “Key Procedures” videos for a limited time. Starting in March 2016, the videos will be viewable only by JBJS EST subscribers.
JBJS Editor’s Choice: IM Nails vs Hip Screws—How Many More Trials Do We Need?
In the December 2, 2015 issue of The Journal, Reindl et al. report on the results of a multicenter randomized trial comparing intramedullary (IM) fixation versus sliding hip screws for stabilization of type A2 unstable intertrochanteric fractures. This trial is yet another product of the Canadian Orthopaedic Trauma Society (COTS), which has collaborated on high-quality clinical trials for more than a decade.
There have been more than 20 RCTs comparing intramedullary fixation with sliding hip screws. Many of these trials exclusively investigated stable fracture patterns or included both stable and unstable fractures. These studies generally concluded that nails provide no clear outcome benefits, except perhaps in unstable fractures. Several meta-analyses have also been published that identified no significant difference in clinical or functional outcomes.
Up until now, there has been little dispute with the recommendation that unstable intertrochanteric fractures be fixed with intramedullary implants. While this current trial confirms radiographic advantages to IM fixation (significantly less femoral-neck shortening) after 12 months, Reindl et al. found but no significant functional advantage (in terms of Lower Extremity Measures, Functional Independence Measures, or timed up-and-go tests) with IM fixation in unstable A2 fractures. These findings add more evidence to the claim that IM implants for both stable and unstable patterns are overused in North America.
The question now becomes how many more trials do we need to further make the point? We know that powerful surgeon-behavior influences exist in academic medical centers that continue to use intramedullary implants routinely for intertrochanteric hip fractures (see the 2010 JBJS prognostic study by Forte et al.). Considering the much higher cost of intramedullary nails relative to hip screws, it is high time that these same centers teach appropriate use of IM implants for these fractures so that trainees become facile with both implant types.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Tool for Pre-TJA Risk Stratification Piloted
A case-control study by Boraiah et al. in the December 2, 2015 JBJS describes a risk-stratification tool that helps predict which patients undergoing total joint arthroplasty (TJA) are likely to be readmitted to the hospital after discharge. The authors used the tool—dubbed the Readmission Risk Assessment Tool, or RRAT—preoperatively among 207 patients who were subsequently readmitted after primary TJA and two cohorts of 234 patients each (one random and one age-matched) who were not.
The total RRAT score for each individual is the cumulative sum of all scores for modifiable risk factors such as infection, smoking, obesity, diabetes, and VTE. Non-modifiable risk factors such as age, sex, race, and socioeconomic status are not included in the scoring system.
The median RRAT score for those readmitted was 3; the median RRAT score for those not readmitted was 1. An RRAT score of ≥3 was significantly associated with higher odds of readmission. Surgical site infection was the most common cause of readmission (found in 45% of the 207 readmitted patients).
The authors note that in the current and future climate of value-based health care, “any unplanned readmission will have financial consequences on the provider and health-care institution”—not to mention the burden readmissions place on patients. While admitting that the RRAT needs to be further evaluated and validated in larger cohorts and that it may not be possible to modify individual risk factors into “an acceptable range” prior to TJA, the authors suggest that risk stratification with the RRAT “can present a ‘teachable moment’ and an opportunity for shared decision-making discussions.”
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