Archive | February 2016

JBJS Reviews Editor’s Choice–Genes and Frozen Shoulder

As new advances in medical technology lead to treatments for injuries and diseases, one concept that has emerged is the importance of genetic predisposition to health, sickness, and functional recovery after trauma. Indeed, as the future of medicine will most likely concentrate on health as opposed to health care, understanding the genetic predisposition to medical conditions will become paramount. In the February 2016 issue of JBJS Reviews, Prodromidis and Charalambous focus on the role of genetics in the development and treatment of frozen shoulder. This article represents a careful analysis of the relationship between genetics and disease.

Frozen shoulder, or adhesive capsulitis, is a common condition that leads to functional loss and impairment of activities of daily living. However, despite the prevalence of this condition, its pathogenesis is not fully understood. Prodromidis and Charalambous performed a systematic review and meta-analysis in order to assess the evidence that suggests a genetic link to frozen shoulder.

The investigators performed a literature search of MEDLINE, EMBASE, and CINAHL using relevant keywords and found an initial 5506 studies. After further screening, seven studies were analyzed. The results were fascinating. One study, involving 1828 twin pairs, showed an 11.6% prevalence and demonstrated a heritability of 42% for frozen shoulder after adjusting for age. In a second study, involving 273 patients, 20% of patients with frozen shoulder had a positive family history involving a first-degree relative. A third study, involving 87 patients, showed that 29% of patients with frozen shoulder had a first-degree relative with this condition.

Two further studies evaluated racial predilection. One of these studies (50 patients) showed a substantially higher number of white patients with frozen shoulder than black patients with the condition. The other study (87 patients) showed that being born or having parents or grandparents who were born in the British Isles were risk factors for this condition.

Finally, four immunological studies investigated HLA-B27 as a risk factor for frozen shoulder. A meta-analysis of two of these studies with clearly defined controls showed higher rates of HLA-B27 positivity in patients with this condition as compared with controls (p < 0.001).

Thomas Einhorn, Editor

JBJS Reviews

Among Large-Diameter MoM Hip Implants, Durom Has Highest Metal Ion Level

In a May 2011 supplement to The Journal of Bone & Joint Surgery, Lavigne et al.  reported results from a prospective two-year study looking at blood metal-ion levels in patients who received one of four types of large-head, metal-on-metal THA designs. At that point, the Durom design from Zimmer showed significantly higher blood levels of cobalt and titanium ions than the three other implants (Birmingham from Smith & Nephew, ASR XL from DePuy, and Magnum from Biomet).

The February 17, 2016 JBJS provides an update on the same cohort at five years of follow-up.  By five years, the original 144-patient cohort had diminished to 134, 123 of whom were available for clinical follow-up and 93 of whom had their metal-ion levels analyzed again.

Hutt Study Graph.gif

In terms of WOMAC and UCLA function scores, there were no differences at five years among the implant types. However, the current study revealed that the Durom design produced the highest levels of metal ions in the blood and the highest number of adverse local tissue reactions and revisions. One of the most problematic design factors in all four implants, the authors say, is the junction of the femoral trunnion and head taper or adapter sleeve (see related OrthoBuzz post).

While noting that ion levels in isolation are probably not useful as either diagnostic or screening criteria, the authors say that “ion progression over time may be more useful, and ideally, a multimodal investigative protocol correlating patient symptomatology, ion levels, and cross-sectional imaging would be required.”

Need to “Bone Up” for the Next Recertification Exam?

The  general clinical recertification exam for orthopaedic surgeons is a four-hour, 200-man_on_trainquestion, multiple-choice exam covering clinical material that all orthopaedists should know. The JBJS Recertification Course, in association with the Miller Review Course, is a top-quality, self-paced test-prep solution that you can take from the convenience of home or office—or while on the go.

Each module in the 15-module video course includes pre- and post-test assessments, hour-long video-learning components, and citations to relevant literature. The full 15-module course covers all areas of the recertification exam, or you can customize a 7-module course tailored to your own needs. Plus, earn CME* and SAE credits while you study.

Those attending the AAOS Annual Meeting, March 1-5, 2016
in Orlando, and all recertification-course purchasers during the months of March and April 2016, will receive a 25% discount on the full 15-module course. Stop by the JBJS booth (#1831) during the Annual Meeting, or use the discount code AAOS2016 at checkout.

* This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of The Journal of Bone and Joint Surgery Inc. and Miller Orthopaedic Review Enterprises, LLC. The Journal of Bone and Joint Surgery Inc. is accredited by the ACCME to provide continuing medical education for physicians.
The Journal of Bone and Joint Surgery Inc. designates this internet enduring material for a maximum of 20 AMA PRA Category 1 Credits™ for the 15-module activity and 10 AMA PRA Category 1 Credits™ for the 7-module activity.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Helping Bone-Cell Implants Thrive

Cell-based therapy for serious fractures or large bone defects is promising, but a lack of blood-supplied nutrients and oxygen often impedes survival of live-cell implants. Researchers reporting in Cell Metabolism have found a way to help implanted bone cells overcome those struggles. They preconditioned periosteal cells to survive in hypoxic and ischemic environments by deleting a cellular protein (PDH2), which in turn stabilized the action of another protein (HIF-1α) that helps sustain energy metabolism in nutrient- and oxygen-deprived environments. This strategy increased postimplantation cell survival and improved bone regeneration—and could hasten the clinical translation of this regenerative-medicine approach.

JBJS Inc. Acquires Journal of Orthopedics for Physician Assistants (JOPA)

The JouWinter 2016 cover page for JBJS.jpgrnal of Bone and Joint Surgery (JBJS) Inc. announced that, effective today, the Journal of Orthopedics for Physician Assistants (JOPA) will be added to the JBJS family of publications and products focused on meeting the information needs of musculoskeletal health professionals.

“We at JBJS have long recognized the expertise and support PAs provide to today’s multi-professional medical team,” said JBJS Inc. CEO Paul Sandford. “This acquisition will enable us to build the largest community of PAs in the orthopaedic domain, specifically targeting the needs of PA readers, researchers, and authors.”

Dagan Cloutier, PA-C, Founder and Editor of JOPA, will remain in JOPA’s editorial leadership role. “As the publisher of The Journal of Bone & Joint Surgery—the gold-standard source of information in orthopaedics—JBJS, Inc. is well-positioned to maximize the quality and dissemination of JOPA content,” said Cloutier.

To introduce the entire orthopaedic community to the publishing of JOPA under the aegis of JBJS, Inc., JBJS will offer access to JOPA at no cost to all PAs, nurse practitioners, and other orthopaedic providers who register at the JBJS booth (#1831) during the upcoming AAOS Annual Meeting, March 1 – 5 in Orlando.

DDH Webinar Tomorrow—CME Available

baby pic for social mediaTreating developmental dysplasia of the hip (DDH) with the Pavlik harness is safe and successful in about 90% of cases. But what about the 10% of patients for whom this treatment is not effective or causes complications The complimentary JBJS webinar on Wednesday, Feb. 24, 2016 at 8:00 PM EST will focus on how orthopaedists can:

  • Identify patient characteristics that help predict Pavlik harness failure
  • Understand the role of ultrasound in managing DDH
  • Recognize and prevent complications from using the harness
  • Successfully treat patients who need a post-Pavlik approach

Following presentations about JBJS-published research by Daniel Sucato, MD; Lucas Murnaghan, MD; and Wudbhav Sankar, MD, DDH expert Scott Mubarak, MD will expand on all three author presentations. The last 15 minutes of the webinar will be devoted to a live Q&A session, during which audience members can ask questions of the authors and commentator. The webinar will be moderated by Paul Sponseller, MD.

CME Credit Available
For those who attend this activity live, The Journal of Bone and Joint Surgery Inc. designates this webinar for a maximum of 1 AMA PRA Category 1 Credits™. The Journal of Bone and Joint Surgery Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Click here to register.

JBJS Editor’s Choice—IM Nailing vs Spica Casts for Pediatric Femoral Fractures

swiontkowski marc colorThe study by Ramo et al. in the February 17, 2016 JBJS examines the evolution toward more aggressive operative treatment of children with isolated femoral fractures. This movement started 30 years ago, initially with the notion that adolescents should be treated as adults, with preferential intramedullary (IM) nail fixation. Concerns regarding damage to the femoral-head arterial supply led to the development of nails that could be started at the trochanteric region.

In the five- to twelve-year-old group, the options that have been documented as safe and effective include flexible nailing, plating, and external fixation, each with its own set of advantages and downsides. Fractures in kids ages four and five have generally been treated by spica cast management. However, parental concerns over cast care, more frequent radiographs, and the negative impact on family life have influenced many centers to move toward IM fixation even in this “preschool” age group.

The Ramo et al. study has all the limitations of a retrospective study, but it strongly suggests that in four- and five-year-olds, the radiographic outcomes of nailing and casting are equivalent after a mean follow-up of 32 weeks. These findings will provide some information for a shared decision-making discussion with parents, but as with many topics in pediatric fracture management, the clinical questions raised by this study beg for a prospective, controlled, multicenter trial. I agree with commentator Merv Letts, who points out that the Ramo et al. study raises important and complex clinical and family-environment issues that we need to grapple with as an orthopaedic community, but that more definitive answers will come only with prospective research and longer follow-up periods.

Marc Swiontkowski, MD

JBJS Editor-in-Chief


What’s New in Adult Reconstructive Knee Surgery: 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 January 20, 2016 Specialty Update on adult reconstructive knee surgery:

Nonsurgical Management and Osteotomy

  • A Cochrane database review found that land-based therapeutic exercise programs were modestly beneficial to patients with knee arthritis. Individualized programs were more effective than exercise classes or home-exercise programs.1
  • A study comparing intravenous administration of tanezumab versus naproxen and placebo in patients with hip and knee osteoarthritis found that tanezumab effectively relieved pain and improved function at week 16.2
  • A comparison of platelet-rich plasma (PRP) injections and hyaluronic acid (HA) injections found both treatments to be equally effective in improving knee function and reducing symptoms as measured by the IKDC subjective score.3
  • A study comparing opening-wedge and closing-wedge high tibial osteotomy found that among patients who did not go on to conversion to TKA, there were no between-group differences in clinical or radiographic outcomes at six years of follow-up.

Implants, Instrumentation, and Technique

  • A comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting TKA found no differences in pain, function, and radiographic outcomes at a mean of 5.9 years.
  • A randomized study of 140 patients that compared the use of patient-specific instrumentation (PSI) and conventional instrumentation found no differences in clinical, operative, and radiographic results.4
  • In a randomized trial of 200 patients, the use of electromagnetic computer navigation resulted in insignificantly fewer outliers from the target alignment, compared with the use of conventional instrumentation. There were no between-group differences in clinical outcomes.5
  • In a prospective randomized trial, the use of computer-assisted navigation during TKA resulted in lower systemic embolic loads, compared with TKA performed using conventional intramedullary instrumentation.
  • A randomized controlled trial comparing kinematically and mechanically aligned TKA found that kinematic alignment with patient-specific guides provided better pain relief and restored better function and range of motion than mechanical alignment using conventional instruments.6
  • A randomized study of selective patellar resurfacing in 327 knees followed for a mean of 7.8 years found higher satisfaction among patients with a resurfaced patella.7

Pain and Blood Management

  • A randomized controlled trial comparing femoral and adductor canal blocks found that adductor canal blocks decreased time to discharge readiness without an increase in narcotic consumption.8
  • A trial comparing periarticular injections (PAIs) of liposomal bupivacaine with conventional bupivacaine PAI found no between-group differences in VAS pain scores 72 hours postoperatively or in patient narcotic consumption.9
  • A double-blinded randomized trial comparing topical versus intravenous administration of tranexamic acid found no significant differences in estimated blood loss or complications.

Rehabilitation and Complications

  • A randomized trial of 205 post-TKA patients found no differences in WOMAC scores for pain, function, and stiffness in groups that received telerehabilitation or face-to-face home therapy.
  • A randomized trial found that Kinesio Taping helped reduce postoperative pain and swelling and improved knee extension during early postoperative rehabilitation.10
  • A trial comparing oral edoxaban and subcutaneous enoxaparin for post-TKA thromboprophylaxis found that edoxaban was the more effective agent. The incidence of bleeding events was similar in both groups.11


  1. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL.Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev.2015;1:CD004376. Epub 2015 Jan 9.
  2. Ekman EF, Gimbel JS, Bello AE, Smith MD, Keller DS, Annis KM, Brown MT, WestCR, Verburg KM. Efficacy and safety of intravenous tanezumab for the symptomatic treatment of osteoarthritis: 2 randomized controlled trials versus naproxen. J Rheumatol. 2014 Nov;41(11):2249-59. Epub 2014 Oct 1.
  3. Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, MarcacciM, Kon E. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015Jul;43(7):1575-82. Epub 2015 May 7.
  4. Abane L, Anract P, Boisgard S, Descamps S, Courpied JP, Hamadouche M. A comparison of patient-specific and conventional instrumentation for total knee arthroplasty: a multicentre randomised controlled trial. Bone Joint J. 2015 Jan;97-B(1):56-63.
  5. Blyth MJ, Smith JR, Anthony IC, Strict NE, Rowe PJ, Jones BG. Electromagnetic navigation in total knee arthroplasty-a single center, randomized, single-blind study comparing the results with conventional techniques. J Arthroplasty. 2015Feb;30(2):199-205. Epub 2014 Sep 16.
  6. Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J. 2014 Jul;96-B(7):907-13.
  7. Roberts DW, Hayes TD, Tate CT, Lesko JP. Selective patellar resurfacing in total knee arthroplasty: a prospective, randomized, double-blind study. J Arthroplasty.2015 Feb;30(2):216-22. Epub 2014 Sep 28.
  8. Machi AT, Sztain JF, Kormylo NJ, Madison SJ, Abramson WB, Monahan AM,Khatibi B, Ball ST, Gonzales FB, Sessler DI, Mascha EJ, You J, Nakanote KA, IlfeldBM. Discharge readiness after tricompartment knee arthroplasty: adductor canal versus femoral continuous nerve blocks-a dual-center, randomized trial.Anesthesiology. 2015 Aug;123(2):444-56
  9. Schroer WC, Diesfeld PG, LeMarr AR, Morton DJ, Reedy ME. Does extended-release liposomal bupivacaine better control pain than bupivacaine after total knee arthroplasty (TKA)? A prospective, randomized clinical trial. J Arthroplasty. 2015Sep;30(9)(Suppl):64-7. Epub 2015 Jun 3.
  10. Donec V, Kriščiūnas A.The effectiveness of Kinesio Taping after total knee replacement in early postoperative rehabilitation period. A randomized controlled trial. Eur J Phys Rehabil Med. 2014 Aug;50(4):363-71. Epub 2014 May 13.
  11. Fuji T, Wang CJ, Fujita S, Kawai Y, Nakamura M, Kimura T, Ibusuki K, Ushida H, Abe K, Tachibana S.Safety and efficacy of edoxaban, an oral factor Xa inhibitor, versus enoxaparin for thromboprophylaxis after total knee arthroplasty: the STARS E-3 trial. Thromb Res. 2014 Dec;134(6):1198-204. Epub 2014 Sep 21.

What Really Causes Shoulder Tendinitis Pain?

Calcific tendinitis in the shoulder can be a perplexing problem for orthopaedists and patients. While it’s a painless, asymptomatic condition in some people, for others it’s extremely painful and impairs range of motion and shoulder function.

In the February 3, 2016 edition of The Journal of Bone & Joint Surgery, a prospective cohort observational study by Hackett et al. helps explain why that might be. After immunohistochemically evaluating biopsied tendon samples from three groups of patients (ten with painful calcific tendinitis, ten undergoing rotF2.mediumator cuff repair, and ten “controls” undergoing a surgical stabilization procedure), the authors found a twofold to eightfold increase of nerve markers, neovascularization, macrophages, M2 macrophages, and mast cells in the calcific tendinitis group compared with the two other groups. The authors conclude that these findings “are consistent with the hypothesis that, in calcific tendinitis, the calcific material is inducing a vigorous inflammatory response within the tendon with formation of new blood vessels and nerves.”

In an insightful commentary on the study, Scott Rodeo cites the study’s main limitation—that biopsy specimens from patients with asymptomatic calcific tendinitis were not studied. That leads the commentator to ask what triggers the transition from asymptomatic lesion to an acutely painful one—and to review some of the current explanatory theories. One posits that osteoclasts drawn to the lesion activate resorption of the calcium. Active resorption causes pain, the theory goes, and that’s when patients frequently receive subacromial steroid injections. Dr. Rodeo suggests that subsequent pain relief may arise more from the natural completion of the resorption process than from the treatment.

Dr. Rodeo further discusses the possibility that active cell-mediated calcium resorption might be a response to microscopic tendon injury in the area of the calcific deposit. He also summarizes interesting stem cell-based theories on what might initiate the deposition of calcium crystals in the first place.

JBJS Editor’s Choice—A More Aggressive Approach to Dens Nonunion

swiontkowski marc colorIn the February 3, 2016 JBJS study by Joestl et al., the authors report persistent radiographic nonunions in nearly 100% of 28 geriatric patients five years after being treated nonoperatively for a dens fracture nonunion. Traditionally these older patients were placed in halo vests or hard cervical collars, based on the rationale that frail, elderly patients might not survive upper-cervical fusion. That strategy, however, often results in skin problems, pin-site infections, and chronic upper-cervical and posterior-cranium pain.

With an increasingly elderly population looming during the next two decades, we will be seeing dens injuries and nonunions in higher numbers. The increased numbers of patients presenting with this injury may allow for a carefully planned multicenter randomized controlled trial, but I think the current status of information regarding this fracture is robust enough to suggest the following treatment approach: Much like the way we currently manage elderly patients with hip fractures, we should be prepared to more seriously consider operative treatment for patients over the age of 65 with a dens fracture—especially when there is concern about persistent nonunion and instability or development of neurological impairments. Although that may formerly have been considered an aggressive approach (and may still be ill-advised in high-surgical-risk patients), this study–plus systematic reviews of other smaller cohort studies–provides ample justification to consider proceeding operatively.

Marc Swiontkowski, MD

JBJS Editor-in-Chief