Early on, patients with knee osteoarthritis (OA) often get sufficient pain relief with nonsteroidal anti-inflammatory drugs. But as the condition progresses, many opt for knee replacement. Although knee replacement shows remarkable long-term results, immediate postsurgical pain management is a crucial consideration for orthopaedists and patients.
On Tuesday, December 13, 2016 at 12:30 PM EST, The Journal of Bone & Joint Surgery (JBJS) and PAIN, the official journal of the International Association for the Study of Pain, will host a complimentary webinar focused on relieving pain before and after surgery for knee arthritis.
- Sachiyuki Tsukada, MD, coauthor of a study in JBJS, will compare pain relief and side effects from intraoperative periarticular injections versus postoperative epidural analgesia after unilateral knee replacement.
- PAIN author Lars Arendt-Nielsen, Dr.Med.Sci, will delve into findings from a study examining biomarker and clinical outcomes associated with the COX-2 inhibitor etoricoxib in patients with knee OA.
Moderated by JBJS Associate Editor Nitin Jain, MD, the webinar will include an additional perspective from musculoskeletal pain-management expert Michael Taunton, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all three panelists.
Seats are limited, so register now!
According to Medscape (registration required) and other media reports, President-Elect Donald Trump has tapped Rep. Tom Price, MD (R-GA) to be the next secretary of the US Department of Health and Human Services (HHS).
Dr. Price, an orthopaedic surgeon, became chair of the House Budget Committee in 2014, and he is a member of the GOP Doctors Caucus, which has vigorously opposed the Affordable Care Act (ACA). Dr. Price has introduced ACA-replacement legislation called the Empowering Patients First Act. Among other things, Dr. Price’s legislation would allow Medicare-eligible people to opt out of the program and purchase private health insurance using tax credits. In the bill’s latest form, people between 18 and 35 years of age would also be eligible to receive $1200 in tax credits to buy health coverage on the individual market.
Dr. Price has taken other stands on health care policy that are consistent with a small-government approach, although he did vote for the Medicare Access and CHIP Reauthorization Act (MACRA), which gradually shifts Medicare from a fee-for-service to pay-for-value system.
HHS Secretary nominees face a confirmation vote in the Senate, but by all accounts, Dr. Price’s personality will not get in the way of that. Donald Palmisano, Jr., executive director of the Medical Association of Georgia, told Medscape that Dr. Price is “approachable and accessible to political friends and foes alike.”
In the November 16, 2016 edition of The Journal of Bone & Joint Surgery, Kim et al. improve our understanding of how blood flow is restored to the necrotic femoral head in Legg-Calve-Perthes disease. Using a series of perfusion MRI scans, the authors evaluated 30 hips with Stage-1 or -2 disease; 15 of the hips were treated conservatively, and 15 underwent one of three operative interventions.
Revascularization rates varied widely (averaging 4.9% ± 2.3% per month), but the revascularization pattern was similar, converging in a horseshoe-shaped pattern toward the anterocentral region of the femoral epiphysis from the posterior, lateral, and medial aspects of the epiphysis. The MRIs yielded no evidence of regression or fluctuation of perfusion of femoral heads, which casts some doubt on the proposed repeated-infarction theory of pathogenesis for this disease.
In a related commentary, Pablo Castaneda emphasizes that the study was not designed to evaluate the effects of different treatments, but he says knowing about an MRI pattern that is predictive of final outcomes in Legg-Calve-Perthes disease “has potential for improving our prognostic abilities.” Still, neither the commentator nor the authors suggest routinely obtaining serial MRIs in this patient population.
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, Aaron Chamberlain, MD, MSc, a co-author of the October 19, 2016 Specialty Update on Shoulder and Elbow Surgery, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.
Reverse Shoulder Arthroplasty
Optimizing reverse shoulder arthroplasty implant design continues to be a research focus. There is significant variation among different implants with regard to the amount of lateralization of the center of rotation, and how lateralization affects clinical outcomes is of particular interest. Authors randomized patients to undergo reverse shoulder arthroplasty with a center of rotation at the native glenoid face or with lateralization.1 Postoperative functional results at a mean follow-up of 22 months were similar between groups overall. However, when the analysis excluded patients with teres minor muscle degeneration, patients with a more lateralized center of rotation had a greater improvement in external rotation. This may portend a benefit of lateralization in the setting of an intact posterior rotator cuff.
Rotator Cuff Tear Natural History
A Level-I prospective cohort study of patients with asymptomatic rotator cuff tears evaluated patterns of tear progression over time.2 Of specific interest was whether the integrity of the anterior supraspinatus cable influenced tear size and/or risk for tear enlargement. Cable-disrupted tears were 9 mm larger at baseline, but cable integrity did not influence risk for tear enlargement or time to enlargement. This understanding may help inform patient discussions about the risks of nonoperative management of rotator cuff tears.
Rotator Cuff Repair
Do patients with symptomatic degenerative rotator cuff tears fare better with surgery or nonoperative management? Only three prospective randomized trials have been published comparing outcomes after randomizing patients to nonoperative management or surgical repair. This Level-I trial randomized patients (mean age of 61) with degenerative full thickness cuff tears to either a course of non-operative management (corticosteroid injection, physical therapy, and oral analgesics) or surgical rotator cuff repair. 3 Patients who underwent surgery experienced a greater reduction in VAS pain and VAS disability scores compared with the nonoperative cohort at 1 year of follow-up.
In another prospective randomized study, authors randomized patients who were ≥55 years of age with painful degenerative supraspinatus tears into one of three treatments: 1) physical therapy alone, 2) acromioplasty and physical therapy, and 3) rotator cuff repair, acromioplasty, and physical therapy. Patients in this study were older than those in the study mentioned above, with a mean age of 65 (range 55 to 81). At the 2-year follow-up, no significant differences among the three interventions were seen in the Constant score, VAS pain score, or patient satisfaction. This data supports initial conservative treatment in older patients with degenerative atraumatic cuff tears. However, the importance of tear progression over time and the age threshold that separates “older” patients from “younger” patients remain to be determined.
Can we improve the biologic healing environment for rotator cuff repair healing? A Level-I prospective randomized controlled study evaluated leukocyte and platelet-rich fibrin in rotator cuff repairs.4 Patients underwent arthroscopic rotator cuff repair with and without leukocyte and platelet-rich fibrin applied to the repair site. No beneficial effect of leukocyte and platelet-rich fibrin was found in overall clinical outcome, healing rate, postoperative defect size, and tendon quality at the 1-year follow-up. A reliable biological augmentation solution for rotator cuff healing remains elusive.
1 Greiner S, Schmidt C, Herrmann S, Pauly S, Perka C. Clinical performance of lateralized versus non-lateralized reverse shoulder arthroplasty: a prospective randomized study. J. Shoulder Elbow Surg. [Internet]. 2015;24(9):1397–404. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002864doi:10.1016/j.jse.2015.05.041
2 Keener JD, Hsu JE, Steger-May K, Teefey SA, Chamberlain AM, Yamaguchi K. Patterns of tear progression for asymptomatic degenerative rotator cuff tears. J. Shoulder Elbow Surg. [Internet]. 2015 Dec 1;24(12):1845–1851. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615004759
3 Lambers Heerspink FO, van Raay JJAM, Koorevaar RCT, van Eerden PJM, Westerbeek RE, van ’t Riet E, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J. Shoulder Elbow Surg. [Internet]. 2015;24(8):1274–81. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002852doi:10.1016/j.jse.2015.05.040
4 Zumstein MA, Rumian A, Thélu CÉ, Lesbats V, O’Shea K, Schaer M, et al. SECEC Research Grant 2008 II: Use of platelet- and leucocyte-rich fibrin (L-PRF) does not affect late rotator cuff tendon healing: a prospective randomized controlled study. J. Shoulder Elbow Surg. [Internet]. 2016 Jan 1;25(1):2–11. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615005388
One of the observations that I have made during my years in academic medicine is that the more popular a topic appears to be in the literature, the less likely we are to really understand it. After all, if we need to write about it so much, it must mean that there is still much to learn. This certainly seems to be the case with regard to injuries of the anterior cruciate ligament (ACL). ACL injuries are among the most common injuries sustained in the United States. Over 100,000 ACL reconstructions were performed in the United States in 2006, and the annual rate has continued to increase over time. Although some patients have achieved good results after nonoperative treatment, a survey of the American Orthopaedic Society for Sports Medicine showed that the majority of respondents used nonoperative treatment for fewer than 25% of their patients with ACL injuries.
Noyes et al.1 described the so-called “rule of thirds.” According to this rule, one-third of patients with an ACL injury will compensate well with nonoperative treatment (copers), one-third will avoid symptoms of instability by modifying activities (adapters), and one-third will require operative reconstruction (noncopers). Unfortunately, there does not seem to be any way to predict which group an individual patient will fall into. Thus, there is still substantial ambiguity in determining which patients are most likely to benefit from early intervention with ACL reconstruction following injury.
In this month’s issue of JBJS Reviews, Secrist et al. used the literature to perform a comparison of operative and nonoperative treatment of ACL injuries. They noted that only 3 randomized controlled trials have compared operative and nonoperative treatment of ACL injuries and that 2 of those studies involved the use of ACL suturing as opposed to more modern forms of reconstruction. The third study involved only 32 patients. All studies had substantial methodological limitations. The authors concluded that there have been no Level-I studies comparing ACL reconstruction with nonoperative treatment.
In their review article, Secrist et al. attempted to define and evaluate the available data on the natural history of nonoperatively treated ACL injuries and to determine how the functional outcomes and injury risks associated with nonoperative treatment compared with those associated with reconstruction. Moreover, they sought to define prognostic factors and rehabilitation protocols associated with successful operative outcomes. Finally, they compared the outcomes following early versus delayed ACL reconstruction.
However, by the end of the article, one gets the feeling that the authors have “come full circle.” The authors summarize their findings by saying that some patients can cope with a torn ACL and return to preinjury activity levels, including participation in pivoting sports. On the other hand, patients who have an ACL injury along with a concomitant meniscal injury are at increased risk for osteoarthritis, and it is unclear what effect reconstruction of an isolated ACL has on future osteoarthritis risk in ACL-deficient patients who are identified as “copers.”
I suspect that we will continue to see articles on this topic for many years to come. In light of the “rule of thirds” and the additional impact of meniscal injury, the allocation of a particular patient to operative or nonoperative treatment remains unclear.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
- Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983 Feb;65(2):163-74 Medline.
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 7-year-old girl who sustained a wrist injury from a fall off of monkey bars. An initial lateral radiograph is shown here. Clinicians attempted a closed reduction and applied a long arm cast. At the 1-week follow-up visit, radiographs showed additional displacement and increased dorsal angulation.
Select from among five possible choices for the greatest predictor of fracture displacement in the setting of distal radial metaphyseal fractures: increased fracture obliquity, a cast index ratio of less than or equal to 0.7, short arm casting, an intact ulna, or increased initial displacement of the radius.
In the past several years, the orthopaedic community has become highly engaged in improving the follow-up management of patients presenting with fragility fractures. We have realized that orthopaedic surgeons are central to the ongoing health and welfare of these patients and that the episode of care surrounding a fragility fracture represents a unique opportunity to get patients’ attention. Using programs such as the AOA’s “Own the Bone” registry, increasing numbers of orthopaedic practices and care centers are leading efforts to deliver evidenced-based care to fragility-fracture patients.
In the November 16, 2016 edition of The Journal, Aspenberg et al. carefully examine the impact of the anabolic agent teriparatide versus the bisphosphonate risedronate on the 26-week outcomes of more than 170 randomized patients (mean age 77 ±8 years) who were treated surgically for a low-trauma hip fracture. This investigation is timely and appropriate because our systems of care are evolving so that increasing numbers of patients are receiving pharmacologic intervention for low bone density both before and after a fragility fracture.
The secondary outcomes of the timed up and go (TUG) test and post-TUG test pain were better in the teriparatide group, but there were no differences in radiographic fracture healing or patient-reported health status.
Although this study was designed primarily to measure the effects of the two drugs on spinal bone mineral density at 78 weeks, these secondary-outcome findings confirm the value of initiating pharmacologic intervention early on after a fragility fracture, whether it’s a bisphosphonate or anabolic agent. The orthopaedic community needs to continue leading multipronged efforts to deal with the public health issues of osteoporosis and fragility fractures.
Click here for additional OrthoBuzz posts related to osteoporosis and fragility fractures.
Marc Swiontkowski, MD
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Having passed the half-century mark with continued relevance, this classic JBJS article by T.G. Barlow, published in the British volume in 1962, rewards the reader with pearls and insights that can still help us make good decisions about treatment of infants with hip dysplasia. Exploring new approaches always pays rich dividends, and this report details Barlow’s observations from a five-year study (1957-1962) in which he examined all newborns at his hospital and followed them up at one year of age. This effort was undertaken at a time before the emerging field of pediatric orthopaedics had many full-time adherents.
Barlow studied nearly 10,000 newborns at the Hope Hospital in Manchester, England. He conducted the first examinations during the first week of life, in an era when newborns in the UK stayed in the hospital for at least one week. He carefully recorded his findings and made observations on incidence of hip dislocation, natural history, and treatment.
His first contribution, for which he is still remembered, was to show that in newborns, with their low resting muscle and tissue tension, the Ortolani test is often subtle, and a dislocated hip may escape notice. The Ortolani test was often impressive in older babies, but less so in newborns. Therefore, Barlow devised his eponymous test, which increases the proprioceptive feedback by applying axial pressure and provoking subluxation or dislocation. Simply put, it is often easier to feel the hip displacing with pressure than to feel it slip back in. The number of babies who have benefited from this method of early detection is too numerous to count!
Barlow’s other observations are equally relevant and useful. He observed that many babies with dislocatable but non-dislocated hips will stabilize naturally. He showed that only one-eighth of unstable hips will have a persistent dislocation, which is why we now only treat dislocated hips immediately upon detection. Recent articles1 have added further insights in this regard.
Barlow also showed that with a program of screening and treatment, no patient in his experience presented at a year of age with a hip dislocation. We still debate the proper method of early detection, but he properly targeted the neonatal period as the time that instability usually begins. Barlow also demonstrated a simple abduction splint made of aluminum and leather that holds the hips in flexion and abduction. Although the Pavlik harness has become more popular as an initial treatment, experts have recently come to realize that a fixed-angle brace can benefit some children who do not stabilize in a Pavlik.2
This classic article was fun to re-read and remains useful to general and pediatric orthopaedic surgeons. Barlow’s disciplined undertaking has shaped our understanding of this important disorder. The man and his insights are remembered for good reason.
Paul D. Sponseller, MD
JBJS Deputy Editor
- Upasani VV, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016 Jul 20;98(14):1215-21
- Sankar WN, Nduaguba A, Flynn JM. Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip. J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7.
The Fall 2016 JBJS JOPA is now available. To access the new issue, go to the JBJS JOPA website, click on the journal image to the right, and download the PDF. Topics include:
- A Visual Guide to the Salter-Harris Pediatric Fracture Classification System
- Perioperative Pain Management in the Chronic Opioid User
- Radiation Safety for PAs in the Orthopaedic Operating Room
- Recap of the monthly image quizzes, including November’s quiz on Distal Radial Metaphyseal Fractures.
With your JOPA subscription, you receive complimentary access to JBJS Reviews, which delivers new online review articles weekly, with a CME opportunity attached to each article.
Create your account and gain access to these important orthopaedic resources/opportunities:
- Writing/video incentive program for PAs and NPs
- Physician Assistants in Orthopaedics: A Study of Job Satisfaction, Education and Lifestyles, A Research Brief from JBJS JOPA
- A salary and call survey for orthopaedic PAs.
How best to treat clavicle fractures remains a controversial question in orthopaedics. A study by Huttunen et al. in the November 2, 2016 JBJS does not resolve that controversy, but it sheds a little light on it.
The authors analyzed a validated Swedish hospital-discharge registry and determined that 44,609 clavicle fractures occurred in that country between 2001 and 2012. During that period, the incidence of clavicle fractures increased by 67%, from 35.6 to 59.3 per 100,000 person-years. During that same time, the rate of surgically treated clavicle fractures increased by 705%, from 2.5% of all clavicle fractures in 2001 to 12.1% in 2012. Surgical treatment was more common in men and in younger age groups. Nevertheless, nearly 90% of clavicle fractures were treated nonsurgically in 2012.
Huttunen et al. remain ambivalent in the discussion section of their study, saying that these and other recent findings “may support surgical treatment of young, active patients who need to return to their previous level of activity in the shortest possible time,” while noting that “high-quality evidence that surgery produces superior long-term results compared with nonoperative treatment remains lacking.”