Archive | December 2016

Long-Term, Latarjet Beats Bankart for Anterior Shoulder Instability

Barkart vs Latarjet_12_7_16.gifIn a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.

Specific 10-year outcome comparisons included:

  • Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
  • Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
  • Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
  • Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group

Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”

What’s New in Orthopaedic Rehabilitation

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, Nitin Jain, MD, MSPH, a co-author of the November 16, 2016 Specialty Update on Orthopaedic Rehabilitation, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.

Back Pain

–A prospective cohort study1 evaluating the benefit of early imaging (within 6 weeks of index visit) for patients ≥65 years old with new-onset back pain found that those with early imaging had significantly higher resource utilization and expenditures compared with matched controls who did not undergo early imaging. One year after the index visit, authors found no significant between-group differences in patient-reported pain or disability. They concluded that “early imaging should not be performed routinely for older adults with acute back pain.”

–A randomized clinical trial2 comparing 10 days of NSAID monotherapy with 10 days of NSAIDs + muscle relaxants or opioids for acute nonradicular low back pain found no significant differences across the groups for pain, functional impairment, or use of health care resources. The authors said these findings suggest that combination therapy is not better than monotherapy in this situation, and that the use of opioids in such patients is not indicated.

Rotator Cuff Tears

–A two year follow-up of a randomized trial comparing three treatments for supraspinatus tears (physiotherapy, physiotherapy + acromioplasty, and rotator cuff repair + acromioplasty +physiotherapy) found no significant pain or function differences among the three groups. However, mean tear size was significantly smaller in the cuff-repair group than in the other two.

Pain Medicine

–A meta-analysis3 investigating the use of cannabinoids for managing chronic pain and spasticity concluded that those substances reduced pain and spasticity more than placebo, but the benefits came with an increased risk of side effects such as dizziness, nausea, confusion,  and loss of balance.

Psychosocial Factors

–A randomized controlled trial4 comparing a phone-based cognitive-behavioral/physical therapy (CBPT) program to standard education following lumbar spine surgery found that patients in the CBPT group had greater decreases in pain and disability and increases in general health and physical performance.

References

  1. Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW,Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar17;313(11):1143-53.
  2. Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
  3. Whiting PF, Wolff RF, Deshpande S, DiNisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73.
  4. Skolasky RL, Maggard AM, Li D, Riley LH 3rd., Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil. 2015 Jul;96(7):1200-7. Epub 2015 Mar 28.

JBJS Editor’s Choice—Nonunions of Foot/Ankle Fusions Matter

Ankle_Fusion_12_7_16.pngIn the December 7, 2016 issue of JBJS, Krause et al. analyze data from a 2013 industry-sponsored RCT to investigate correlations between nonunions of hindfoot/ankle fusions indicated by early postoperative computed tomography (CT) and subsequent functional outcomes. Whether nonunion was assessed by independent readings of those CT scans at 24 weeks or by surgeon composite assessments at 52 weeks, patients with failed healing had lower AOFAS, SF-12, and Foot Function Index scores than those who showed osseous union.

This study suggests that a CT should be obtained from patients who are at least 6 months out from a surgical fusion and are not progressing in terms of activity-related pain and function. Depending on the specific CT findings, a repeat attempt at bone grafting, with the possible addition of bone-graft substitute and/or possible modification of internal fixation, may be warranted to forestall later clinical problems.

Krause et al. imply that trusting plain radiographs that show no indication of fusion failure is not acceptable when patient pain and function do not improve in a timely fashion.  Conversely, they conclude that their findings do not support “the concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well),” because nonunions identified early by CT eventually resulted in worse clinical outcomes. The authors also noted that obesity, smoking, and not working increased the risk of nonunion, corroborating findings from earlier studies.

While advanced imaging such as CT is not necessary in foot/ankle fusion patients who are improving in terms of function, pain, and swelling , this study stresses the importance of achieving union following these fusion procedures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

A Close Look at Crossovers in Knee RCTs

partial_meniscectomyIn a November 16, 2016 JBJS study whose findings have implications for both research and practice, Katz et al. analyzed data from the MeTeOR trial to answer two questions:

  • What prompts patients with meniscal tears and knee osteoarthritis who are randomized to physical therapy (PT) in trials comparing PT to arthroscopic partial meniscectomy (APM) to cross over from nonoperative therapy to APM?
  • Do those who cross over to APM receive symptom relief that’s comparable to those originally randomized to APM?

After careful multivariate analysis of 48 patients who crossed over in the MeTeOR trial (representing 27% of those originally randomized to PT), the authors identified two factors associated with a higher likelihood of crossover: a baseline WOMAC Pain Score of ≥40 and symptom duration of <1 year.  The authors also found that patients who crossed over to APM were just as likely to experience improvement in pain scores as those originally randomized to APM.

From a research standpoint, the authors suggest that future investigators may wish to make “special efforts” to keep patients who present with severe pain and relatively short symptom duration in nonoperative therapy. Clinically, Katz et al. say the findings “underscore the emerging treatment recommendation…to try a PT regimen before opting for APM.”

Guest Post: Will Rep-Less ORs Improve Surgical Consistency?

OrthoBuzz occasionally receives posts from guest bloggers. The following commentary comes from David Kovacevic, MD in response to a November 14, 2016 article in The Washington Post.

Sandra G. Boodman’s recent column in The Washington Post, ”Why is that salesman in the operating room?… sheds light on the potential for conflicts of interest and other possible pitfalls of having device reps in the OR.  Currently, device reps are required to abide by the ethical standards set forth by AdvaMed, a medical device trade association. In addition, the American Academy of Orthopaedic Surgeons has adopted standards of professionalism regarding orthopaedist-industry conflicts of interest.

Both device rep and surgeon should have one common goal—to do what is in the best interest of the patient. Ultimately, though, the surgeon is responsible for patient welfare and safety.  This includes thorough pre-surgical planning; expertise in surgical anatomy, approach, and technique; complete knowledge about surgical instrumentation and implantable devices; and total transparency in the doctor-patient relationship.  The competent surgeon also manages the surgical team, collaborates with the anesthesia team, and recognizes the device rep’s adjunct role.

The presence of device reps in the operating room should be limited to answering implant-specific questions for the surgical team.  Patient-care problems can arise when the surgical team leader (i.e., the attending surgeon) and surgical team rely too heavily on device reps for technical expertise and assistance.  This can lead to questions as to who really is in charge and accountable.

Several solutions exist for sidestepping such ambiguity.  The consent-for-surgery form should state explicitly that a device rep may be present in the procedure room, and the device rep should wear scrubs or a disposable head cover that is a different color from the OR attire worn by surgical and anesthesia teams. The most effective solution, though, lies in building, developing, and sustaining surgical teams focused on improving operating room efficiency and consistency.  That’s a large undertaking, and the culture change needed for it requires buy-in from multiple stakeholders, such as the medical director of perioperative services, departments in the supply chain, and leaders in anesthesia, surgery, and nursing.

One rationale for a rep-less model is to reduce the cost of implants by working directly with and purchasing from the implant manufacturer and bypassing the group purchasing organization, sales reps, and distributors.  As Boodman’s article explains, for Loma Linda University Medical Center this meant obtaining device inventory directly from the implant manufacturer and training one of its surgical technicians as a de facto rep. The result was at least a 54% reduction in total case costs for primary total hip and total knee replacement procedures and empowering surgical technicians with additional knowledge about implants. It is too early to tell whether this model enhances consistency in the operating room, decreases operative time, or reduces length of stay and 30-day hospital readmission rates.

We should expect ongoing scrutiny of the device rep’s role in the operating room. With help from surgeons, hospitals and health systems should consider developing more effective surgical teams, including surgical techs specially trained about implants, to improve patient outcomes and consistency.

David Kovacevic, MD is associate fellowship director of shoulder and elbow surgery and assistant professor in the Department of Orthopaedics & Rehabilitation at Yale University School of Medicine. He can be reached at david.kovacevic@yale.edu or @KovacevicMD.

 

Updated Knee Content from JBJS

knee-spotlight-image.pngThe recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.

Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of December 2016:

  • Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection to the Knee Following Partial Medial Meniscectomy

  • Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age

  • Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee

  • Weight-Bearing Compared with Non-Weight-Bearing Following Osteochondral Autograft Transfer for Small Defects in Weight-Bearing Areas in the Femoral Articular Cartilage of the Knee

  • Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques

Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.

Visit the JBJS Knee Spotlight website today.

New JBJS Virtual Recertification Course Now Available

11-2016_VCR_II_Template-Final.jpgThe Second Edition of the JBJS Virtual Recertification Course, in association with the Miller Review Course, is now available.  Featuring 15 updated modules, the course now includes the option to purchase bundles of 3 modules to address your specific educational needs.  Presented by top lecturers, the course is approved for 22.5 AMA PRA Category I credits™ and ABOS-approved for 10 self-assessment examination (SAE) credits.

Each module includes pre- and post-test assessments, hour-long video-learning components, and citations to relevant literature.

Click here to purchase the full 15-module course or five different 3-module bundles.

Topics/faculty presenters include:

  • Adult Hip Reconstruction by Dr. James Browne
  • Adult Knee Reconstruction by Dr. Edward McPherson
  • Basic Science by Dr. Winston Gwathmey
  • Foot and Ankle by Dr. Steven Haddad
  • Hand and Wrist by Dr. Sanjeev Kakar
  • MRI by Dr. Timothy Sanders
  • Pediatric Orthopaedics by Dr. Jeremy Rush
  • Orthopaedic Oncology by Dr. Ginger Holt
  • Rehabilitation by Dr. MaCalus Hogan
  • Spine by Dr. Francis Shen
  • Sports: Upper Extremity by Dr. Kevin Plancher
  • Sports: Lower Extremity by Dr. Mark Miller
  • Test Prep/Statistics by Dr. Stephen Thompson
  • Trauma: Pelvic and Upper Extremity by Dr. Thomas Schaller
  • Trauma: Lower Extremity by Dr. Michael LeCroy