Archive | June 2016

“Limited Role” for Hip Arthroscopy in Tönnis Grade-2 Arthritis

Arthroscopy to THA Conversion.gifMany orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).

The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.

There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.

From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”

JBJS: Highest 2015 Impact Factor Among Ortho Journals

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For the second year in a row, The Journal of Bone & Joint Surgery (JBJS) has topped the field of orthopaedic journals in Impact Factor (IF). The Impact Factor measures the citation performance of a journal over a two-year period.

According to data from the 2015 edition of Journal Citation Reports (JCR), the JBJS Impact Factor is 5.163—the only orthopaedic journal to have an IF above 5.0. JBJS articles were cited a total of 3,268 times during 2013 and 2014, a 10.5% increase relative to the prior two-year period. In addition, The Journal’s five-year Impact Factor, an even more robust representation of sustained impact, was 5.372.

Although the Impact Factor is just one metric by which The Journal’s influence on musculoskeletal care is measured, our highest-in-the-field number is a testament to the ceaselessly hard working editors, reviewers, and authors who are responsible for the practice-changing content we publish.

For those of you interested in revisiting the most influential work in orthopaedics, according to JCR data, here are the top-three cited JBJS articles published in 2013-2014:

Jason Miller, JBJS Executive Publisher

JBJS Editor’s Choice—Perfusion Key to Preventing Osteonecrosis in SCFE

ICP Probe.gifOsteonecrosis of the femoral head is a dreaded complication for patients with a slipped capital femoral epiphysis (SCFE). This complication is far more common with acutely displaced and unstable slips. Safely reducing the femoral head back on the neck while preserving blood supply can often be accomplished with closed reduction maintained by in situ cannulated screw fixation, although some recent efforts to treat SCFE have focused on open approaches.

In the June 15, 2016 edition of The Journal, Schrader et al. demonstrate the benefits of using a simple intracranial pressure (ICP) monitoring probe (see photo) inserted through the cannulated screw to measure femoral head perfusion. While using this technique intraoperatively on 26 hips with SCFE, the authors encountered six hips in which there was no blood flow to the femoral head after closed reduction and screw stabilization. In these situations, they performed percutaneous capsular decompression.

The fact that all patients—even those with no initial femoral head perfusion—left the operating room with measurable blood flow confirms the long-held principle that lack of perfusion can be treated with capsulotomy. The ICP device uses waveforms to measure blood flow and is an accurate gauge of perfusion. Moreover, the technology is available in most hospitals with trauma centers or neurosurgery services.

Having researched femoral head perfusion myself as a young orthopaedist and having kept abreast of more recent findings in this area, I think the monitoring protocol described by Schrader et al. is the best yet published to limit the devastating complication of hip osteonecrosis. I feel that if ICP monitors are available, this protocol should be adopted by all centers treating patients with acute SCFE.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

What’s New in Foot and Ankle Surgery

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 Sheldon Lin, MD and Michael Yeranosian, MD, co-authors of the May 18, 2016 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies they cited.

Ankle Fractures and Syndesmotic Injuries

–A randomized study compared syndesmotic fixation versus no fixation in patients with supination-external rotation (SER) IV-type ankle fractures and positive intraoperative stress tests (persistent widening of the medial clear space). At four years of follow-up researchers found no clinical or radiological differences between the two groups.1

–A randomized single-blinded trial to help determine optimal methods for soft-tissue management after ankle trauma compared standard treatment using ice and elevation with the use of multilayer compression bandages. Researchers found that multilayer compression therapy resulted in faster resolution of edema than cryotherapy.

Total Ankle Arthroplasty

–A prospective cohort study found that patients undergoing total ankle arthroplasty (TAA) had higher preoperative expectation scores than did those undergoing ankle arthrodesis. TAA patients were also more likely than arthrodesis patients to report improved postoperative satisfaction scores. Postoperative expectation and satisfaction scores in both groups were closely linked to postoperative Ankle Osteoarthritis Scale (AOS) scores. The study emphasizes the importance of preoperative patient education.2

Orthobiologics

–A randomized controlled trial looking at union rates in ankle and hindfoot arthrodesis compared the use of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) plus an injectable osteoconductive beta-tricalcium phosphate (β-TCP) collagen matrix to standard autograft.  Complete fusion of all involved joints at 24 weeks occurred in 84% of those treated with the growth factor-matrix combination and in 65% of those treated with autograft (p <0.001).3

Patient-Reported Outcomes Assessment

–The 10-center Orthopaedic Foot & Ankle Outcomes Research (OFAR) Network conducted a three-month trial of collecting preoperative and six-month postoperative patient outcome information using the Patient Reported Outcomes Measurement Information System (PROMIS). Of the 328 patients enrolled, 76% completed the preoperative instruments and 43% completed the six-month postoperative instruments. Despite substantial loss to follow-up, the OFAR Network process enabled easy data aggregation and analysis, suggesting its utility in facilitating multicenter trials.4

References

  1. Kortekangas THJ, Pakarinen HJ, Savola O, Niinimäki J, Lepojärvi S, Ohtonen P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2014 Oct;35(10):988-95. Epub 2014 Jun 24.
  1. Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
  1. Daniels TR, Younger ASE, Penner MJ, Wing KJ, Le ILD, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW. Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int. 2015 Jul;36(7):739-48.Epub 2015 Apr 6.
  1. Hunt KJ, Alexander I, Baumhauer J, Brodsky J, Chiodo C, Daniels T, Davis WH, Deland J, Ellis S, Hung M, Ishikawa SN, Latt LD, Phisitkul P, SooHoo NF, Yang A, Saltzman CL; OFAR (Orthopaedic Foot and Ankle Outcomes Research Network). The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle. Foot Ankle Int. 2014Sep;35(9):847-54.

 

Insight into Bundled Payments for Orthopaedics

“Alternative payment models are here to stay,” according to an AOA Critical Issues article by Greenwald et al. in the June 1, 2016 issue of The Journal of Bone & Joint Surgery. The article identifies successful implementation strategies related to the Bundled Payments for Care Improvement (BPCI) initiative launched by the Centers for Medicare and Medicaid Services (CMS) in 2013.

Alternative payment models represent an opportunity to reduce costs by eliminating waste and unwarranted variation in care by finding efficiencies within the system. One way to achieve this is through gainsharing incentives that align hospitals, physicians, and post-acute care providers in the redesign of care. But participants also assume financial risk.

Orthopaedics plays a big role in the BPCI risk-reward initiative. Sixteen of the 48 clinical “episodes of care” included in BPCI are orthopaedic-related. Moreover, three episodes (major lower-extremity joint replacement, femur/hip/pelvis fractures, and “medical non-infectious orthopaedic”) account for 40% of the 16 orthopaedic episodes being evaluated.

The nuts and bolts—and risks and rewards— of the initiative are well-described in the article, but here are several pearls extracted therefrom:

“Care improvement activities and care redesign…are the necessary prerequisites before entering into bundled payment arrangements.”

“The financial risk is real [because] outliers, those patients whose cost is substantially higher than the mean patient cost, cannot be controlled.”

“It is important that the physician or surgeon responsible for the patient is involved in all stages of the episode of care and interacts with all of the parties involved.”

“Specific to orthopaedics, there are substantial opportunities for cost savings by integrating preoperative and intraoperative processes, reviewing implant purchasing options, and negotiating post-acute care costs.”

“Changes in care delivery often require … managing patient expectations.”

How Safe Are Osseointegrated Implants for Amputees?

Osseointegrated Implant.gifAbout one-third of lower-limb amputees have problems with the socket connecting their residuum to a prosthetic limb. This has led to the development of osseointegrated implants, which consist of a press-fit intramedullary implant that protrudes through the skin to accommodate an abutment to which the prosthetic limb is rigidly attached.

Concerns about ascending infection and related complications with such constructs led Al Muderis et al. to conduct a multicenter prospective cohort study on the safety of osseointegrated implants, published in the June 1, 2016 JBJS. The authors found that mild infection and irritation of soft tissue were common, but that “these complications can be managed with simple measures,” such as outpatient antibiotic treatment.

Specifically, among the 86 patients with a transfemoral amputation and an implant who were followed for a median of 34 months:

  • 31 had no complications
  • 29 had one or more infections (all grade 1 or 2, four of which required surgical debridement)
  • 26 had non-infectious complications (including hypergranulation of the stoma, soft-tissue redundancy, traumatic intertrochanteric fracture, and intramedullary implant breakage)

Smoking and female sex were associated with recurrent and more severe infections, prompting the authors to suggest that those patient characteristics could be “useful criteria for patient counseling and selection.”

In their commentary on the study, Paul Dougherty, MD and Douglas Smith, MD encourage continued research into bactericidal or mechanical barriers to microbial colonization in areas where the implant enters the body. Although no formal cost studies have been done on osseointegrated implants, the commentators reckon that such costs “are likely greater than those for conventional prosthetic management.”

Hi-Value/Hi-Quality CME—Anytime, Anywhere

The first 2016 JBJS Quarterly CME Exam—based on articles published in January, February, and March—is now available.

OEC Logo.pngStarting now and going forward, each interactive quarterly CME experience from JBJS contains 100 questions and is approved for a maximum of 10 AMA PRA Category 1 CreditsTM. Even better, the ABOS has approved the JBJS Quarterly Exams for 10 Self-Assessment Exam (SAE) credits—half of the 20 SAE credits per three-year cycle that you need for Maintenance of Certification (MOC). So you can meet several continuing-education requirements with a single JBJS-vetted learning experience.

Take JBJS Quarterly Exams online anytime, anywhere, with each exam available for one year from time of initial posting.

Cost for the quarterly CME exam is $100, and the exam may be taken multiple times  for review purposes without payment.

Go to the JBJS Orthopaedic Education Center to see the whole course catalog of quarterly, subspecialty, and JBJS Reviews CME options, and start the new quarterly CME activity today.

3-D Printing: An Orthopaedic Update

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to an article at MedCityNews.com that announced a 3-D printing alliance between Johnson & Johnson and HP.

There’s much focus lately on healthcare concepts in which each patient’s treatment is tailored to his or her specific condition, anatomy, and, in some cases, genetic make-up. Within that realm of so-called “personalized medicine,” surgeons are becoming increasingly interested in tailoring procedures and implants to specific individuals. The MedCity News article discusses how Johnson & Johnson has partnered with HP to further develop 3-D printing capabilities, with a goal of giving surgeons more patient-specific options.

3-D_Scaffold.pngOne of the particular devices J & J is pursuing involves 3-D-printed bone-graft cages that form an osteoconductive scaffold for critical-size bone defects. Developing such a scaffold could go a long way toward promoting quicker and better outcomes in cases for which current techniques are very technically demanding.  Three-D printing may eventually deliver a patient-customized scaffold that promotes bone healing, inhibits microbiologic activity, provides biomechanical strength, and is easier for surgeons to use.

The article also discusses how customized 3-D-printed implants have already been used at some facilities for “unique” patients, such as those whose challenging revision surgery would normally require substantial “trial and error” intraoperatively to properly fit implants.  This printing technology can also facilitate production of customized cutting jigs, retractors, and other tools specific to individual patients. Companies are even using 3-D technology to develop casts, braces, and other interventions used in the nonoperative treatment of orthopaedic conditions (see related OrthoBuzz post).

Additionally, 3-D printing can be used in the preoperative period to provide surgeons with a better understanding of the bony anatomy they will encounter during a case. This type of preoperative templating is already being used on complex heterotopic ossification removals, spinal deformity corrections, and other difficult operations.  These 3-D-printed models can also be used to educate patients and increase their understanding of the planned procedure.

Despite all the promise surrounding 3-D printing, hurdles are abundant. For example, an entirely new regulatory framework will need to be developed to ensure the quality and safety of these products. Even if the capabilities of this technology increase and the costs decrease, we must remember the many other exciting device technologies that elicited similar early excitement but were found to be less useful than anticipated.

Nevertheless, companies such as Stryker are already spending hundreds of millions of dollars to build facilities devoted to industrial 3-D printing, and they will be looking for a return on that investment. So, despite the exhilaration and promise that come with new technologies, it is important to recognize their potential limitations—and to have open discussions with patients about all that remains unknown in regard to their use.

Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, NC.

Click here to read a JBJS Reviews article about the surgeon’s role in introducing new orthopaedic technologies.

Single-Shot HA vs Steroid: Similar Outcomes at 6 Months

HA vs Steroid.gifOrthopaedists frequently treat knee osteoarthritis with hyaluronic acid (HA) or corticosteroid injections, but which works better?

The 99 patients in a double-blinded randomized controlled trial by Tammachote et al. in the June 1, 2016 Journal of Bone & Joint Surgery received a single intra-articular injection of either 6 mL of hylan G-F 20, or 1 mL of 40-mg triamcinolone acetonide plus 5 mL of 1% lidocaine. At the six-month follow-up, both groups experienced significant and similar improvements in knee pain, function, and range of motion, without complications. But there were short-term distinctions:  Triamcinolone relieved pain better and faster in the first week, after which the effect became similar to that of HA. Similarly, triamcinolone provided better functional improvement than HA at two weeks post-injection, but the effects of the two drugs were not statistically distinguishable after that.

In commenting on this study, Paul Levin, MD, says that its findings “support the [AAOS] clinical practice guideline of a strong recommendation against the use of hyaluronic acid.” He goes on to do a quick cost analysis showing that if 1.2 million people received a single cortisone injection (approximately $10 each) and another 1.2 million people received a single HA injection (per-injection prices ranging from $250 to more than $1000), the yearly medication cost would be $300 million to $1.2 billion for HA, versus $12 million for corticosteroid.

Dr. Levin says explaining both clinical and cost considerations to patients can be challenging. “It is easier, more efficient, and less acrimonious to comply with our patient’s request for [HA],” he writes. But he reminds orthopaedists that “bioethical principles along with the concept of shared decision-making do require a physician to spend the necessary time to educate his or her patients.”

JBJS Editor’s Choice—How Important Is the Knee’s ALL?

Ligament Robot.gifI think it’s safe to say that the anterior cruciate ligament (ACL) is the most-studied anatomic structure in the musculoskeletal system.  Yet more than a century ago, French surgeon Paul Segond identified a lesser structure in the knee, the anterolateral ligament (ALL), presuming it to be an important stabilizer of that joint. More recent research has associated this ligament with the anterolateral joint line capsular avulsion fragments associated with some ACL ruptures.

A “fashionable” interest in the ALL has re-emerged in that cyclic way orthopaedic surgical techniques and indications are prone to. Some surgeons are designing reconstruction procedures in which the ALL is addressed in addition to the ACL. While this may be a currently “fashionable” approach, carefully collected data presented in the June 1, 2016 issue of The Journal by Thein et al. clarify the biomechanical role of this ligament and suggest that ALL reconstruction is usually unnecessary. Using cadaveric knees and a robot instrumented with a universal force-moment sensor (see photo above), the authors carefully quantify the displacements that result from disruption of the ALL, as well as the load borne by the ligament both when the ACL is intact and disrupted.

Thein et al. conclude that while the ALL “may bear load in the setting of failed ACL reconstruction or chronic complete tears of the ACL,” the ALL carries minimal load in the ACL-intact knee—and that the need for ALL reconstruction “in a well-functioning ACL-reconstructed knee appears to be limited.” This well-conducted piece of research should restrain some of the enthusiasm for including the ALL when reconstructing an ACL-injured knee.

Marc Swiontkowski, MD

JBJS Editor-in-Chief