Archive | May 2016

AOA Symposium: Secondary Fracture Prevention

ownbone_logo-r.pngOn Thursday, June 23, 2016, the American Orthopaedic Association and the National Association of Orthopaedic Nurses will host a full-day symposium focused on how to establish and run a fracture liaison service.

  • When: Thursday, June 23, 2016, 9:00 am to 5:30 pm
  • Where: The Westin Seattle, Seattle, WA

Learn from national and local experts and network with other clinicians interested in secondary fracture prevention programs. JBJS Editor-in-Chief Marc Swiontkowski, MD will be one of the presenters.

Register before June 1 to receive reduced pricing.

Hospital Acquisitions Leveling Off, JBJS Study Finds

About a year ago, JBJS published its third biannual Role of the Orthopaedic Surgeon study. While intended primarily to inform suppliers about the procurement habits and needs of orthopaedic surgeons, this study contains much that is of interest to clinicians.

For example, results suggest that the flurry of independent orthopaedic practice acquisitions by hospitals and health systems has leveled off. After leaping from 19% to 28% between 2012 and 2013, reported practice ownership by hospitals fell a bit to 25% according to the 2015 study.

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By clicking here and filling out a short form, you can download a 22-page executive brief of the 2015 study. Find out whether you and your practice are in step with the following trends:

  • Orthopaedic practices hiring non-surgeons to relieve admin and clinical burdens
  • Orthopaedic practices continuing to expand and diversify service offerings
  • Surgeons retaining strong influence over device and equipment procurement

Coming soon: We’ll be reaching out this summer to orthopaedic surgeons for data for our 2017 Role of the Orthopaedic Surgeon study. That’ll be your best chance to let suppliers know what you want and need from them in order to help your patients.

In the meantime, click here to get a synopsis of what the 2015 study found.

JBJS Case Connections—Arthroscopy Solves Ornery Ortho Problems

Avulsed teres minor.gifThe indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. The May 2016 “Case Connections” article springboards from a May 25, 2016 JBJS Case Connector report about an isolated avulsion of the teres minor tendon that was repaired arthroscopically. That unique case is linked to three others from the JBJS Case Connector archive:

  • Arthroscopic treatment of a knee flexion contracture
  • Arthroscopic reduction/fixation of an acetabular rim fracture
  • Arthroscopically assisted medial femoral condyle reduction

As impressive as these minimally invasive solutions are, orthopaedists should always keep in mind that arthroscopy, like any other surgical procedure, is not without its potential complications (see related “Case Connections” article).

JBJS Reviews Editor’s Choice–How Should New Orthopaedic Technology Be Introduced?

Over the past several decades, orthopaedic surgery has enjoyed an explosion in the development of new technologies. These technologies have largely improved the quality of orthopaedic care. The development of new technologies results in both disruptive and nondisruptive evolution and requires that orthopaedic surgeons gain specific knowledge of their appropriate use in clinical practice.

However, despite the advances developed from orthopaedic innovation, many discoveries have been associated with unanticipated adverse events. As an example, the original total hip replacement developed by Charnley featured a 1-piece femoral component with a 22.5-mm head. This was later changed to a larger-diameter head, resulting in increased volumetric wear of conventional polyethylene. In addition, new implants with sharp corners led to cement fractures and the development of so-called cement disease. More recently, metal-on-metal articulations have been associated with metallic particles and ion-induced bone and soft-tissue destruction. Ceramic-on-ceramic articulations may lead to implant breakage, striped wear, and squeaking. There is no question that total hip arthroplasty is an exceptionally successful technology, but there is concern regarding the way in which improvements and innovations gain regulatory approval and surgeon acceptance.

In the May 2016 issue of JBJS Reviews, Goodman et al. discuss the introduction of new technologies in orthopaedic surgery. They review the use of novel biologics and combination products and, in particular, single out platelet-rich plasma for the insufficient clinical evidence to support its use. Moreover, they describe the initial enthusiasm regarding the use of recombinant human BMP-2 for spine fusions but note that a review of clinical trials has revealed that there may be concerns regarding insufficient numbers of patients to assess safety, under-reporting of serious complications, conflict of interest among the investigators, and potential bias.

Goodman et al. address some very simple but nonetheless profound issues. For example, they ask, “How should new technologies be introduced into orthopaedics?” They further ask, “How should a surgeon learn to use new technology?” Perhaps most importantly, they raise the issue of ethical considerations related to the use of new technology.

The future of orthopaedic innovation looks bright. Some have commented that there are too many perceived barriers to gaining regulatory approval of new technologies. Recently, the structure and methodology by which approval of new medical technology is managed across the United States has come under increased scrutiny.

I do not think you can ever be too safe or too careful. This article by Goodman et al. is an excellent review of the issues and considerations. It’s a quick read but leaves plenty of room for thought!

Thomas Einhorn, Editor

JBJS Reviews

Plusses and Minuses of Capital Femoral Growth Plate Extension

Cam Morphology.gifFemoroacetabular impingement (FAI), especially in adolescent athletes, has received a lot of attention from orthopaedists in the last 15 years. In the May 18, 2016 edition of The Journal of Bone & Joint Surgery, a longitudinal radiographic study by Morris et al. sheds light on how a measurement called the epiphyseal extension ratio (EER) delivers excellent diagnostic accuracy for predicting cam morphology of the femoral head, one of the main causes of FAI.

The authors carefully analyzed at least five consecutive annual hip radiographs from 96 healthy adolescents. Specifically, they measured changes in the anteroposterior alpha angle and the superior EER (the superior epiphyseal extension divided by the femoral head diameter). They found a mean increase in alpha angle and EER between Oxford bone age (OBA) stages 5 and 7/8. The mean EER increased significantly at each stage, with the greatest increase occurring between OBA stages 6 and 7/8.

In this study, the EER showed excellent diagnostic accuracy for predicting a final alpha angle of ≥78, which prior research has suggested is a threshold that predicts an increased risk for developing end-stage hip osteoarthritis. However, as commentator John H. Wedge, MD emphasizes, Morris et al. “do not recommend radiographic screening for this marker.”

Dr. Wedge adds that this study lends credence to the hypothesis that cam deformity develops from chronic impingement before rather than after proximal femoral physeal closure. But perhaps the most interesting messages are in the discussion section, where Morris et al. state that “epiphyseal extension may be a physiologic, protective response to increased physeal shear forces that decreases the risk of progression to SCFE [slipped capital femoral epiphysis].” The authors describe the cam-morphology downside of epiphyseal extension as “the unfortunate long-term consequence of a short-term adaptive response.”

Metal-on-Metal Hip Arthroplasty: Where Do We Go From Here?

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard S. Yoon, MD.

We’re entering the “midterm” follow-up period for the metal-on-metal (MoM) hip devices implanted in the early 2000s, and recent reports from around the world are confirming early concerns. Several studies published during the first few months of 2016 report unacceptably high failure rates.

In the Open Orthopaedics Journal, Mogensen et al. reported an 18.4% revision rate in more than 100 CONSERVE MoM hips, at a mean follow-up of 4.5 years. These results led the Danish authors to terminate the use of MoM at their centers.

In the BMJ Open, Langton et al. reported a 16% failure rate among more than 350 Pinnacle MoM hips after about nine years of follow-up. Greiner et al. published a follow-up of prior research in a recent edition of the Journal of Arthroplasty. Among more than 150 MoM modular acetabular components with 5- to 12-year follow-ups, the results related to adverse local tissue reactions and revisions were inferior when compared with those of metal-on-polyethylene articulations. Dhotare et al., in Hip International, reported an alarming failure-rate increase from 7% at six years to 29% at ten years for the Birmingham MoM cup and large metal head.

While we cannot turn back the clock on the past use of MoM devices, we have some information about surveillance and treatment that may help us prevent catastrophic failure.

Data regarding the effects of increasing serum metal ions are mixed. Some studies have found a direct correlation between high metal ion levels and the incidence of adverse tissue reactions (and the need for subsequent revision), while other studies have not.  A recent JBJS study identified cobalt-ion thresholds that could help stratify patients with Birmingham and Corail-Pinnacle hips who are at low risk of metal-debris adverse reactions.

The systemic effects of increased serum metal ions are also being debated. Some case reports have cited neurotoxicity presenting as tinnitus, gait imbalance, and other issues, while a more recent, larger longitudinal study published in the Journal of Arthroplasty did not confirm this correlation. Those authors surmised that increased serum ion levels may cause neurotoxicity-associated symptoms primarily in MoM patients with metal hypersensitivity.

Metal artifact reduction sequence (MARS) MRI has been helpful in early identification of adverse soft tissue reactions. However, there is no general consensus or guideline as to when and how often this technology should be utilized in order to provide consistent surveillance and/or indications for revision.

While we are still trying to understand the finer points of the many variables related to MoM, there is an obvious need to forge consensus. Recently, in the Bone and Joint Journal, Berber et al., representing the International Specialist Centre Collaboration on MoM Hips (ISCCoMH), conducted a survey among six international tertiary referral centers to assess the overall consensus in surveillance and treatment practices. Only a moderate agreement value (kappa = 0.6) was found. This inconsistent agreement led the group to call for international coordination to help set forth guidelines that would standardize and improve surveillance of and treatment for those with MoM hips.

Richard S Yoon, MD is executive chief resident at the NYU Hospital for Joint Diseases.

Own the Bone Webinar: Assessing Osteoporosis Risk Factors

On Thursday, May 26, 2016, at 6:00 pm EST, the Own the Bone initiative will offer a webinar titled “Assessing Risk factors to Determine Osteoporosis Treatment.”

OwnBone_Logo-RJohn Schousboe, MD, PhD, director of the Osteoporosis Center at Park Nicollet Clinic in Minnesota, will discuss how to identify the factors that make patients more susceptible to fragility fractures. Learn about the tools available to help you evaluate patient fracture risk, including the most well known, FRAX, and two additional validated tools.

The American Orthopaedic Association (AOA) developed Own the Bone as a quality improvement program to address the osteoporosis treatment gap and prevent subsequent fragility fractures.

What’s New in Sports Medicine

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. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, OrthoBuzz asked Warren Dunn, MD, a co-author of the April 20, 2016 Specialty Update on sports medicine, to select the five most clinically compelling findings from among the more than 30 studies cited in the article.

Shoulder

–What happens to asymptomatic rotator cuff tears over time?  According to a long-term prospective study of patients who had an asymptomatic tear in one shoulder and a symptomatic contralateral rotator cuff tear, the asymptomatic tears enlarged in almost one-half of the patients over a median of three years. Those patients who experienced tear enlargement tended to have an onset of new pain and progressive degenerative changes within the supraspinatus and infraspinatus muscles. The authors concluded that many formerly asymptomatic tears will progress to become symptomatic.

–Does tendon repair yield better outcomes than physical therapy (PT) when treating rotator cuff tears? A randomized trial of 103 patients with tears not exceeding 3 cm found that 12 of 51 patients (24%) in the PT group subsequently underwent secondary cuff repair over a 5-year follow-up period. Statistically, patients in the primary repair group had significantly better group-mean improvements on the Constant score, ASES score, and VAS for pain and patient satisfaction than those who underwent secondary repair, but the authors noted that these differences “may be below clinical importance.” Thirty-seven percent of those treated with PT only experienced a >5 mm increase in tear size, which was associated with inferior outcomes.

–Are estimates of Propionibacterium acnes colonization rates in surgical shoulder wounds accurate? A controlled diagnostic study examined P. acnes colonization in 117 open shoulder surgeries that utilized the deltopectoral approach. In 20.5% of the procedures, at least one surgical specimen was positive for P. acnes growth, but 13% of cultures from sterile-sponge control samples also had positive growth. This led the authors to surmise that prior estimates of P. acnes incidence may be higher than actual because of frequent culture contamination. Male sex and preoperative corticosteroid injections were associated with a higher likelihood of bacterial growth.

Knee/ACL

–Most people who undergo ACL reconstruction experience significant improvement in physical quality of life and quality-adjusted life years, but who is more or less likely to benefit? A 2- and 6-year longitudinal analysis of a multicenter cohort found that those who underwent revision, smoked cigarettes, had lateral tibial plateau chondromalacia, or had less education were more likely to score lower on the Physical Component Summary of the Short Form-36. Those who tended to have higher postoperative functional scores were those with higher baseline function, younger age, lower BMI, and either no lateral meniscal treatment or >50% lateral meniscectomy.

Hamstring Injuries

–Hamstring injuries are common among soccer players. A Level I randomized controlled trial among 579 high-level amateur soccer players found that 13 weeks of participation in Nordic hamstring exercises significantly reduced injury incidence and risk for injury compared with a control group over a 1-year period. No differences in injury severity were found.1

Reference

  1. van der Horst N, Smits DW, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015 Jun;43(6):1316-23. Epub 2015 Mar 20.

JBJS Editor’s Choice—Racial Disparities Persist in Trauma Care

swiontkowski marc colorThe orthopaedic community has been aware of racial disparities in care delivery for two decades. The phenomenon has been most clearly elucidated in joint replacement surgery, but in the May 18, 2016 edition of The Journal, Dy et al. confirm that the issue is also at play in hip fracture care.

The authors analyzed the prospectively collected records of nearly 200,000 New York State residents who underwent hip fracture surgery between 1998 and 2010. After multivariable adjustment for factors such as patient characteristics and hospital/surgeon volume, Dy et al. found that black patients were at significantly greater risk for delayed surgery, a reoperation, readmission, and 1-year in-hospital mortality than white patients. The authors also found that patients covered by Medicaid (a marker for low socioeconomic status) were at increased risk for delayed hip-fracture surgery.

It is time for the orthopaedic community to develop an organized strategy to deal with this important social issue. Recruitment into the ranks of orthopaedists of underrepresented minorities, enhanced cultural-sensitivity training, and culturally relevant patient and family educational materials may begin to address the situation. Perhaps the AAOS, the AOA, and the J. Robert Gladden Orthopaedic Society could convene a meeting to develop such a strategic plan? I am confident we can begin to reduce racial and socioeconomic disparities if we put our collective minds to it.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

Arms at Risk: Elbow Abnormalities Common Among Little Leaguers

LL Pitcher.jpgHere we are in the heart of Little League season, with an estimated 2.5 million kids out there playing. However, the rate of arm injuries in the 10- to 13-year-old population of baseball players has increased in the last two decades, despite the implementation of pitching guidelines.

In the May 4, 2016 edition of The Journal, Pennock et al. report findings from a prospective study of 26 Little League players whose elbows were physically examined and evaluated with MRI before the start of the season. Here are some salient results:

  • Nine players (35%) had 12 positive MRI findings, including seven instances of edema of the medial epicondyle apophysis.
  • Surprisingly, the prevalence of positive MRI findings and a history of arm pain were not greater in pitchers and catchers when compared to other position players.
  • Those with a positive MRI finding had greater reduction in shoulder internal rotation compared with the nondominant arm.
  • Year-round play (i.e., playing ≥8 months per year) and working with a private coach were associated with positive MRI findings and a history of elbow pain.

Noting that 27% of the players in this study used a private coach, Pennock et al. concluded that “ultimately, a balance must be found between teaching proper throwing mechanics and excessive throwing.” The authors also suggest that guidelines be revisited to address year-round play.