Archive | September 2016

Soccer Players Benefit from Ankle-Injury Prevention Programs

6580f_sports-medicine-devices-marketA Level-I meta-analysis by Grimm et al. in the September 7, 2016 issue of The Journal of Bone & Joint Surgery found a significant reduction in the risk of ankle injury among soccer athletes who participated in ankle-injury prevention programs. Researchers reviewed data from 10 randomized controlled trials of such prevention programs involving more than 4,000 female and male soccer players, applying random-effects statistical models to determine pooled risk differences. Not surprisingly, the authors found substantial heterogeneity among the included studies, but there was no evidence of publication bias.

Despite the overall finding of a protective effect from prevention programs, the authors were “unable to comment on the role of individual elements of injury prevention programs,” saying that further research is needed to evaluate the effectiveness of specific exercises and the optimal timing and age for implementing these programs.

Peer Review Week: Day 2

JBJS is helping celebrate Peer Review Week 2016 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2016, JBJS will profile three different top reviewers on OrthoBuzz. Today, let’s meet Gwo-Chin Lee, Michelle Ghert, and Michael McKee:

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Gwo-Chin Lee, MD
University of Pennsylvania

What do you like best about reviewing for JBJS?
It gives me a pulse of all of the interesting and hot topics of research occurring in our field and helps me focus my own research initiatives and clinical practice.
How do you find time to review for JBJS?
I make it a priority as best as I can to review for the journal.  I see it as not only a service and a way to give back, but also an educational opportunity for me.
What do you see as JBJS’ role in shaping the future of orthopaedics?
The journal is the premier orthopaedic publication and forum for orthopaedic research.  As it moves onto other educational ventures, it will continue to be a vehicle for the orthopaedic community to communicate, disseminate, and innovate

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Michelle Ghert, MD
McMaster University

What do you like best about reviewing for JBJS?
The work is interesting and helps me keep up with knowledge in my field. I also feel that reviewing is an important service to the academic community.
How do you find time to review for JBJS?
I set aside some time on my research days.
What do you see as JBJS’ role in shaping the future of orthopaedics?
JBJS is an important source of knowledge dissemination in orthopaedics and a forum for advanced research methodology.

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Michael McKee, MD
University of Toronto

What do you like best about reviewing for JBJS?
Reviewing keeps me abreast of the latest clinical and research developments.
How do you find time to review for JBJS?
I dedicate a set time each week for reviews.
What do you see as JBJS’ role in shaping the future of orthopaedics?
JBJS is the premier journal for orthopaedics, adaptable and flexible, and it will continue to flourish in this.

JBJS Editor’s Choice: Short (or No) Hospital Stays for TJAs

swiontkowski marc color.jpgIn the September 7, 2016 issue of The Journal, Sutton III et al. report results from a sophisticated analysis of the National Surgical Quality Improvement Program (NSQIP) database confirming that hospital discharge 0 to 2 days after total joint arthroplasty (TJA) is safe in select patients in terms of 30-day major-complication and readmission rates. Large dataset analyses like this represent the next step in confirming what has been going on at the grass-roots level across the world—a movement toward outpatient TJAs and/or very early discharges following those procedures. (See related “Global Forum” article in the July 6, 2016 JBJS.)

This trend has been associated with very high patient satisfaction and low morbidity. The movement away from multiple-day hospital admission and toward rapid discharge to home or alternative postoperative care environments such as hotels or rehabilitation centers has far surpassed the novelty stage and is under way in every major metropolitan area around the world. The trend is a welcome motivation for us to address patient expectations for the postoperative period, which are specifically linked to more judicious use of narcotic medication accompanied by regional and local anesthetic efforts and liberal use of nonsteroidal anti-inflammatory medication. Total joint replacement is the ideal surgical intervention to lead this no- or short-hospitalization movement because of the standardized surgical approaches and requirements for implants, blood-loss management, and thromboprophylaxis.

I envision a time in the not-too-distant future where 80% to 90% of musculoskeletal post-intervention care takes place outside of the hospital environment, a shift that will require efficient use of remote-monitoring technology and continued improvement in post-intervention pain management. Hospitals will then become the setting for very complex events like organ transplantation, appropriate intensive care, and high-level trauma care. This will result in lowering the overall cost of care, improving patient satisfaction (who among us would not rather sleep in our own bed?), and minimizing nosocomial complications.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Peer Review Week: Day 1

JBJS is helping celebrate Peer Review Week 2016 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2016, JBJS will profile three different top reviewers on OrthoBuzz. Today, let’s meet Kim Templeton, John Birch, and Kanu Okike:

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Kimberly Templeton, MD
University of Kansas Medical Center

What do you like best about reviewing for JBJS?
Reviewing for JBJS is another way for me to give back to a profession that has meant so much to me. It also allows me to keep up to date on current trends in research, which helps in formatting education programming for our residents.
How do you find time to review for JBJS?
I review for JBJS between cases, while sitting at airports waiting for planes, or any other downtime that I can find. Because of the importance of the work of JBJS to me, I find a way to fit reviewing into my schedule.
What do you see as JBJS’ role in shaping the future of orthopaedics?
As JBJS is a go-to journal in residency education, the research that is published is informing the education of the next generations of orthopaedic surgeons. Discussing articles within JBJS not only provides opportunities for discussion of current trends in the field but also important areas such as appropriate research design, interpretation of results, and other areas such as applicability of results based on the sex of the patient and other social determinants of health.

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John G. Birch, MD
Texas Scottish Rite Hospital for Children

What do you like best about reviewing for JBJS?
I have a “passive” opportunity to learn what is new and developing in my
specialty.
How do you find time to review for JBJS?
It’s surprisingly easy, since a review doesn’t leave me messages or demand an
immediate response. I can read the manuscript quickly, think about it, read it again, simultaneously creating a list of questions/suggestions.
Any of these tasks are “pigeon-holed” into larger responsibilities.
What do you see as JBJS’ role in shaping the future of orthopaedics?
The demanding, earnest, blinded peer-review process effectively guarantees quality research publication that the readers may rely on for veracity and timeliness.

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Kanu Okike, MD
Kaiser Moanalua Medical Center

What do you like best about reviewing for JBJS?
In reviewing for JBJS, I have the opportunity to help shape the future of our field.  The articles published in JBJS are often quite influential, and I enjoy contributing to the process by which these articles are selected and improved via the peer-review process.
How do you find time to review for JBJS?
Like many academically-oriented surgeons, I try to set aside time each week for research.  For me, this time includes not only doing my own research, but also contributing to the peer-review process as a reviewer for JBJS.
What do you see as JBJS’ role in shaping the future of orthopaedics?
High-quality research is paramount for the continued advancement of orthopaedic surgery.  Given that JBJS is currently the highest-impact journal in the field, the articles printed on its pages have the potential to greatly influence orthopaedic practice.

Hyaluronic Acid Injections for Treatment of Advanced Osteoarthritis of the Knee: Utilization and Cost in a National Population Sample

untitled-1There is a rise in knee osteoarthritis, particularly in the aging U.S. population. A practice known as hyaluronic acid (HA) injections is used for the treatment of knee osteoarthritis; however, its efficacy and cost-effectiveness are being debated. In this study, the utilization and costs of HA injections were evaluated during the 12 months preceding total knee arthroplasty (TKA) and the usage of HA injections in end-stage knee osteoarthitis management in relation to other treatments was also evaluated. Truven Health Analytics databases (MarketScan Commercial Claims and Encounters and Medicare Supplemental and Cooridination of Benefits) were reviewed in order to find patients who underwent TKA from 2005 to 2012. All patient-specific osteoarthritis-related health care, including medications, corticosteroid injections, HA injections, imaging, and office visits, as well as payment information were analyzed during the 12 months before TKA.

244,059 patients met the inclusion criteria, and 35,935 (14.7%) of them had > 1 HA injections in the 12-month period. HA accounted for 16.4% of all payments related to osteoarthritis, coming in second only to imaging studies (18.2%). In terms of treatment-specific payments, HA injections accounted for 25.2%, a rate higher than that of any other treatment. Compared with patients who did not receive HA injections, patients who had the injections were significantly more likely to receive additional knee osteoarthritis-related treatment.

HA injections are still frequently used to treat osteoarthritis of the knee even though there have been numerous studies that question their efficacy and cost-effectiveness for that purpose. Based on the results and a lack of data supporting the effectiveness of HA injections in the current cost-conscious health-care climate, the authors of this study concluded that decreasing the use of HA injections for patients with end-stage knee osteoarthritis may substantially reduce cost without adversely affecting the quality of care.

Guest Post: Osteoporosis Treatment Still Lacking

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD, in response to a study published in JAMA about a new agent to prevent fractures in postmenopausal women with osteoporosis.

The August 16, 2016 issue of JAMA published the results of the ACTIVE (Abaloparatide Comparator Trial In Vertebral Endpoints) trial.  This 28-site randomized trial allocated postmenopausal women with low bone mineral density (BMD) and/or a prior fragility fracture into one of three arms:  abaloparatide (80 µg subcutaneously, daily ) vs. daily placebo injection vs. teriparatide (20 µg subcutaneously, daily).  The primary end point was new vertebral fracture over the 18-month trial.

As expected, both anabolic agents significantly outperformed placebo, with incident vertebral fractures occurring in only 4 subjects in the abaloparatide arm (0.6%) and 6 in the teriparatide arm (0.8%), while there were 30 in the placebo arm (4.2%).  Although the study was not powered to evaluate differences between the two anabolic agents, the results suggest that abaloparatide and teriparatide performed essentially the same over the 18-month period.

In an accompanying commentary,1 Cappola and Shoback note that institutional review boards (IRBs) approved a prospective clinical trial protocol in which patients with known osteoporosis and/or a prior fragility fracture were allowed to be randomized to a non-treatment arm for 18 months.  Subjects whose BMD dropped more than 7% from baseline and those who experienced an incident fracture during the trial “were offered an option to discontinue and receive alternative treatment,” but in some sense IRB approval of this protocol implicitly acknowledged that osteoporosis is undertreated.

Turning back to the study itself, I noted with interest that subjects who had regularly used bisphosphonates in the last 5 years or denosumab in the last year were excluded.  So, none of the 2463 subjects who were randomized had received any active treatment for osteoporosis in the 1 to 5 years prior to enrollment, despite the fact that the average T-score in the lumbar spine (-2.9 for all 3 arms) was in the osteoporotic range and that almost one-third of subjects had had at least one prior fragility fracture.

This is a sad commentary on “our” (meaning all providers involved in bone health) continued inability to diagnose and treat osteoporosis effectively.  Despite the “National Bone and Joint Health Decade” (2002-2011) and our continued attempts to “Own the Bone,” we have made little progress in recognizing and treating the osteoporosis underlying the fragility fractures that we so frequently treat.  Colleagues of mine and I published that only 38% of patients in 2002 with clinically diagnosed vertebral compression fragility fractures were receiving active treatment for osteoporosis.2  Over the ensuing decade, Solomon et al. showed that that figure actually decreased to 20%.3

This JAMA study provides empiric Level-I support for the efficacy of another anabolic agent to treat osteoporosis.  Cost, subcutaneous delivery, and osteosarcoma concerns have limited the only FDA-approved anabolic osteoporosis medication, teriparatide, to second-line status, behind bisphosphonates.  If and when approved, abaloparatide will probably bump up against the same limitations.  Still, the parathyroid hormone receptor agonists are particularly pertinent to orthopaedic surgeons, because they are the most effective secondary fracture prevention agents—and the only ones that show meaningful improvement in bone mineral density.  This bone-building property has also led to progressive acceptance of teriparatide as an important perioperative adjunct for instrumented spinal fusion surgery in patients with known osteoporosis.

However, as has been repeatedly shown, parathyroid receptor agonists only work when they are prescribed, and they are only prescribed when osteoporosis is diagnosed.2,3  Patients with incident clinical fragility fractures need to be effectively educated about osteoporosis, its treatment, and the impact of failing to treat it.  Orthopaedic surgeons need to continue to set the signal flares and advocate for our patients to receive effective treatment for all their chronic musculoskeletal illnesses, not the least of which is osteoporosis.

References:

  1. Cappola AR, Shoback DM. Osteoporosis Therapy in Postmenopausal Women With High Risk of Fracture. JAMA. 2016 Aug 16;316(7):715-6.
  1. Freedman BA, Potter BK, Nesti LJ, Giuliani JR, Hampton C, Kuklo TR. Osteoporosis and vertebral compression fractures-continued missed opportunities.Spine J. 2008 Sep-Oct;8(5):756-62.
  1. Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res. 2014 Sep;29(9):1929-37.

JBJS Reviews Editor’s Choice—Trunnion Wear After THA

Modular NeckTotal hip arthroplasty made its debut about 60 years ago. As with most new technologies, it was anticipated that advances and improvements would occur. However, the improvements have been incremental and in some cases have led to problems, particularly with regard to interchangeable parts, modularity, and the materials used for articulating surfaces. Some still believe that total hip arthroplasty was close to being optimized at the time that it was introduced.

Some may view these comments as somewhat provocative, but I would not be surprised if a lot of surgeons agree. The issue of trunnion wear is one example of these problems. One of the main contributing factors is the fact that each implant manufacturer uses tapers with their own specifications, which vary in terms of angle, diameter, straightness, roundness, and surface properties. Therefore, most femoral neck implant tapers are not necessarily compatible with each other. It is important to note that femoral heads should not be used interchangeably between designs as the cone angle may differ. ?If this is done, trunnionosis will be a likely outcome.

In the August 2016 issue of JBJS Reviews, Lanting et al. provide an important and very worthwhile discussion of the risk factors for trunnionosis. Trunnionosis may be enabled by the disruption of the protective oxidative layer on the metal by fretting, potentiating the corrosion of the exposed metal beneath the oxidative layer through an active combination of biochemical and electrochemical processes. Time in vivo consistently has been shown to be a risk factor for trunnionosis. Flexural rigidity of the trunnion has been demonstrated to have an important role in the development of trunnionosis. A flexible trunnion may allow fretting as well as point loading. Edge loading is known to make tribocorrosion more likely to occur. In the presence of any degree of angular mismatch, the effect of trunnionosis may be increased.

The role of design and manufacturing variables in the development of trunnion problems continues to be debated. Surgeon-related factors, especially the greater variability and taper assembly with smaller-incision surgery, also may contribute to this phenomenon. Patients presenting with unexplained pain who have modular neck-body implants should be considered to have an adverse local tissue reaction resulting from corrosion of the neck-stem interface as potential cause of the pain.

In most cases, I suspect that removal of the femoral head, cleaning of the taper, and replacement with a different femoral head (usually a ceramic head with a titanium adapter sleeve) represents adequate treatment based on care recommendations. In contrast, in cases involving adverse local tissue reactions associated with the modular neck designs, removal of the modular stem and neck may be required.

Thomas A. Einhorn, MD
Editor, JBJS Reviews