Archive | May 2018

An Increased Lateral Femoral Condyle Ratio Is a Risk Factor for Anterior Cruciate Ligament Injury

The purpose of this study was to examine the relationship between distal femoral morphology and anterior cruciate ligament (ACL) injury, ACL reconstruction (ACLR) failure, and contralateral ACL injury. https://jbjs.org/reader.php?source=The_Journal_of_Bone_and_Joint_Surgery/100/10/857/abstract&id=30301&rsuite_id=1666295#info #JBJSInfographics #VisualAbstract

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Progression of Cervical Spine Degeneration Over 20 Years

Few studies have addressed in detail long-term degenerative changes in the cervical spine. https://jbjs.org/reader.php?source=The_Journal_of_Bone_and_Joint_Surgery/100/10/843/fulltext&id=30295&rsuite_id=1666209#info #JBJSInfographics #VisualAbstract

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Call for Submissions: JBJS What’s Important Articles

Warren WI for OBuzzOver the last two years, JBJS has published more than 20 What’s Important articles, with topics ranging from unhappy patients to innovations in orthopaedic education. In these 1,000-word articles, clinicians tell a thoughtful and personal story about a high-impact lesson they learned at some juncture in life that altered their worldview, enhanced them personally, and positively affected the care that they provide as orthopaedic physicians.

Because they are personal in nature, “What’s Important” submissions are not subject to the usual stringent peer-review process. Instead, they are reviewed by the Editor-in-Chief, who  corresponds with the author if revisions are necessary and makes the final decision regarding acceptance. The accepted manuscript is then forwarded to JBJS staff for copyediting and publication.

Authors of these articles have received many comments suggesting that readers value What’s Important articles in unique ways. If you would like JBJS to consider a “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

JBJS 100: Massive Rotator Cuff Tears, Continuous Passive Motion

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears
L M Galatz, C M Ball, S A Teefey, W D Middleton, K Yamaguchi: JBJS, 2004 February; 86 (2): 219
In one of the earliest studies to investigate the relationship between the anatomic integrity of arthroscopic rotator cuff repair and clinical outcome, these authors found that the rate of recurrent defects was high but that at 12 months after surgery, patients experienced excellent pain relief and functional improvement. However, at the 2-year follow-up, the clinical results had deteriorated substantially. Investigations into the relationship between cuff-repair integrity and clinical outcomes are ongoing.

The Biological Effect of Continuous Passive Motion on the Healing of Full-thickness Defects in Articular Cartilage: An Experimental Investigation in the Rabbit
R B Salter, D F Simmonds, B W Malcolm, E J Rumble, D Macmichael, N D Clements: JBJS, 1980 January; 62 (8): 1232
In this paper, Salter and colleagues hypothesized that “continuous passive motion [CPM] of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.” They found that CPM stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion, and since then CPM has been commonly used in humans after cartilage repair. However, CPM’s actual efficacy in people—after cartilage repair or total knee arthroplasty—remains controversial.

Preparing PRP: More Questions than Answers

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

The use of platelet-rich plasma (PRP) in the treatment of tendinitis, some sports injuries, and osteoarthritis has been popularized over the past decade. Because there is “minimal” manipulation of biologic products such as PRP, their preparation is not subject to the rigid standards used for the development of pharmacologic products.

In a recent study of autologous PRP, investigators hypothesized that “lower levels of inflammatory cytokines (ICs) within PRP stimulate positive chondrocyte and macrophage responses irrespective of the age and OA disease state of the PRP donor”1. To test this hypothesis, investigators made PRP preparations from young healthy individuals and older patients with end-stage OA using a modified double-spin protocol. The level of inflammatory cytokines (ICs) was identified in all PRP preparations. Chondrocytes were isolated from normal-appearing cartilage harvested from an arthritic knee during total joint arthroplasty. Alginate beads were created for culture and were treated with 10% PRP on days 0 and 2 of a 4-day culture period.

The results contradicted the hypothesis. There were a number of adverse results in the cultures treated with PRP donated by the OA group. Macrophage activation increased with OA disease status/age of the PRP donor. PRP from OA subjects significantly upregulated TNF-α (p <0.001) and MMP-9 (p<0.0001) in macrophage cultures irrespective of whether the PRP had “high” or “low” IC levels. Additionally, PRP from donors with OA decreased Col2a1 (p<0.05) and SOX9 (p<0.05) expression more than PRP from healthy donors, irrespective of IC grouping.

According to these findings, the functional effects of PRP appear to be dependent on the age and disease status of the plasma donor, as opposed to the IC concentration. This suggests that a more complex interaction with age or OA-related molecular factors might dictate the effect of PRP.

In a separate study, the issue of variation of PRP preparations in research was evaluated by Delphi consensus and other methodologies.2 One key consensus of the PRP experts was the importance of detailing the cellular composition of whole blood and the delivered PRP. The experts also noted marked individual variation in PRP and the need for a clear understanding of the factors influencing such variation.

References

  1. O’Donnell C, Migliore E, Grandi FC, Lingampalli N, Raghu H, Giori N N, J, Indelli PF, Robinson WH, Bhutani N, Chu CR. Donor Specific Effects of Platelet-Rich Plasma for the Treatment of Osteoarthritis Trans Orthop Res Sco. 2018. Paper 0063
  2. Murray IR, Geeslin AG, Goudie EB, Petrigliano FA, LaPrade RF. Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO): Platelet-Rich Plasma and Mesenchymal Stem Cells. J Bone Joint Surg Am. 2017 May 17;99(10):809-819. doi: 10.2106/JBJS.16.00793

What’s New in Foot & Ankle Surgery 2018

foot-ankle-for-obuzz.jpegEvery 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, a co-author of the May 16, 2018 Specialty Update on Foot and Ankle Surgery, to select the five most clinically compelling findings from among the 60 studies cited in the article.

Ankle Arthroscopy
—A recent Level-I study1 investigated the efficacy of preemptive local anesthesia in combination with general or spinal anesthesia in 80 patients undergoing ankle arthroscopy. The authors found that patients receiving local anesthesia did not require any on-demand pain medication and reported lower pain intensity up to 24 hours post-arthroscopy. Patients in the spinal anesthesia-only group had better pain control than did patients receiving general anesthesia only.

Hallux Rigidus
—While arthrodesis of the first metatarsophalangeal (MTP) joint is the preferred treatment for this condition among most providers, concerns over medial column lengthening and degenerative changes at adjacent joints have led to continued interest in MTP arthroplasty. In a 15-year follow-up of 52 patients randomized to MTP joint arthrodesis or arthroplasty2, Stone et al. found that those who underwent arthrodesis had less pain, fewer revisions, and greater satisfaction than those in the arthroplasty group, with equal function scores. On the basis of these data, arthrodesis remains the treatment of choice for severe hallux rigidus.

Total Ankle Arthroplasty (TAA)
—In a prospective study of 451 patients with an average follow-up of 4.5 years, Lefrancois et al. compared clinical and functional outcomes of 4 TAA prostheses: the HINTEGRA implant, the Agility implant, the Mobility implant, and the Scandinavian Total Ankle Replacement (STAR). Patients with the Mobility implant had less improvement in scores on the Ankle Osteoarthritis Scale, while the other 3 implants had comparable results.

—In a matched cohort study of more than 3,000 patients examining the complication rates of TAA versus those of arthrodesis, Odum et al. found that patients undergoing arthrodesis had a 1.8-times higher risk of a major perioperative complication than those undergoing TAA.

Plantar Fasciitis
—In a randomized controlled trial of 50 patients investigating the efficacy of botulinum toxin for treating plantar fasciitis3, Ahmad et al. found that patients in the botulinum toxin group had improved function and pain scores compared with the placebo group at 6 and 12 months post-injection, as well as a lower rate of surgical treatment for recalcitrant symptoms (0% versus 12%).

References

  1. Liszka H, Gądek A. Preemptive local anesthesia in ankle arthroscopy. Foot Ankle Int. 2016 Dec;37(12):1326-32. Epub 2016 Sep 12.
  2. Stone OD, Ray R, Thomson CE, Gibson JNA. Long-term follow-up of arthrodesis vs total joint arthroplasty for hallux rigidus. Foot Ankle Int. 2017 Apr;38(4):375-80. Epub 2016 Dec 20.
  3. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int. 2017 Jan;38(1):1-7. Epub 2016 Oct 1.

Scoliosis Management Shows Success Long-Term

Scoliosis for OBuzzHealth-related quality of life (HRQOL) in adulthood is an important outcome measure for patients diagnosed with juvenile or adolescent idiopathic scoliosis. In the May 16, 2018 issue of The Journal of Bone & Joint Surgery, a cross-sectional study of 1,187 Swedish patients with scoliosis by Diarbakerli et al. reveals patient-reported HRQOL outcomes at an average follow-up of approximately 18 years. Using the Scoliosis Research Society-22r (SRS-22r) and the EuroQol 5-Dimensions (EQ-5D) instruments, the authors analyzed outcomes among those who had been untreated (n = 347), brace-treated (n = 459), or surgically treated (n = 381) in accordance with standards at the time of diagnosis.

The surgically treated group had significantly lower scores in the SRS-22r domains of function and self-image, compared with the scores in those domains among the other two groups. According to Daniel J. Sucato, MD, who commented on the study, those findings “most likely reflect the various effects of the surgical procedure, including the stiffness imparted by the arthrodesis of the spine,… stiffness of the soft tissues, and the presence and awareness of implants and a surgical incision.” Diarbakerli et al. also found that untreated patients did not report a decrease in HRQOL with age.

Interestingly, patients treated surgically had higher SRS-22r satisfaction-domain scores than brace-treated patients, even though overall SRS-22r and EQ-5D scores were lower among surgically treated patients than brace-treated patients. For spine surgeons, one key finding was that “a more caudal extent of fusion may be one of the most important characteristics that negatively affects quality of life” in patients undergoing scoliosis surgery.

With its large number of patients and long-term, patient-focused outcomes, this study generally corroborates findings from previous, smaller studies. But, as Dr. Sucato points out in his commentary, “the brace and surgical groups had treatments that were current at the time but not relevant today, especially as they involved the use of first-generation techniques and instrumentation.”

Impact of Clinical Practice Guidelines on Use of Injections for Knee OA

Knee Injection for OBuzzIn a recent OrthoBuzz post, I commented on the apparent benefits to patients when Scottish hip-fracture guidelines were followed. Now, in a “closer-to-home” study in the May 16, 2018 issue of JBJS, Bedard et al. examine the effects of AAOS clinical practice guidelines (CPGs) on the use of injections for knee osteoarthritis (OA). The authors used an insurance database housing more than 1 million knee OA patients to evaluate the change in rates of corticosteroid and hyaluronic acid injections from 2007 to 2015. This date range includes the periods before and after the publication of the AAOS CPGs for knee arthritis (both the first edition, published in early 2009, and the second edition, published in late 2013).

The authors found that the rate of hyaluronic acid injections by orthopaedic surgeons decreased significantly after both publications of the guidelines and that the utilization of corticosteroid injections appears to have plateaued since the most recently published guidelines. Still, almost 40% of all of the patients in the cohort received a corticosteroid injection, with 13% having received a hyaluronic acid injection. In absolute numbers, those percentages represent more than half a million injections, despite the facts that the evidence supporting either injection for the treatment of knee OA is weak at best and that almost half of the patients receiving one of these injections ended up getting a total knee replacement within a year.

While the changes in practice revealed by Bedard et al. may seem relatively small, they are a step in the right direction toward value-based care.  CPGs are easy to pick apart, but they are developed carefully and for a good reason—to provide us with evidence-based recommendations for excellent patient care. It is gratifying to see that such guidelines are having a positive impact in our field.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Botox May Relieve Persistent Tennis Elbow

Botox for Tennis ElbowLateral epicondylar tendinopathy (“tennis elbow”) that is refractory to the usual interventions of physical therapy/home-directed exercise, ice therapy, corticosteroid injections, and rest is a relatively common but very difficult clinical situation. Patients often become frustrated by the lack of improvement and want something to alleviate the pain and disability. However, the orthopaedic community has been reluctant to recommend surgical intervention except for the most severe cases because the outcomes of this surgery are not as predictable as we would like.

It is within this context that Creuzé et al., in the May 16, 2018 issue of The Journal, present results from a double-blind randomized trial elucidating the impact of low-dose Botulinum toxin injection on this chronic condition. Just over half of the patients treated with the Botulinum toxin injection (n = 29) had a >50% reduction in their initial pain intensity at day 90, and almost 20% felt completely cured. Those results were significantly better than those experienced by the group treated with placebo injections (n = 28).

Kudos to the industry sponsor of this study for supporting the double-blind design, because it removed a significant potential bias that might have otherwise tainted the results. The only fault I can find in the trial is a lack of reporting on the patients’ hand dominance and the magnitude of functional demand on their affected limbs. Before and after treatment, a patient who uses power tools with a dominant and affected limb during a physically demanding job may well have more severe symptoms than a person who works at a computer and whose dominant and affected limb is the “non-mouse” extremity.

It is rare indeed to find a study that blinds the administrator of an orthopaedic intervention, as injections and oral medications are not the most prominent tools in our predominantly surgical armamentarium. The inclusion criteria in the Creuzé et al. study reflected a realistic but difficult patient-enrollment scenario—a minimum of 6 months of symptoms (a mean of almost 19 months) despite previous attempts at all other well-known interventions.  The fact that nearly all subjects in both groups had a previous steroid injection into the extensor carpi radialis brevis (ECRB) muscle and continued to experience symptoms confirms the difficulty of these cases and represents what many patients go through in search of an effective treatment.

Furthermore, the fact that only 50% of patients in the intervention group achieved significant pain relief reflects the refractory nature of this condition in many patients. These findings seem to indicate that surgical intervention will remain a necessary component of care for patients with lateral epicondylitis who are not cured by Botulinum toxin injection or other, more common treatment modalities—and that we should pay attention to improving surgical outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS 100: Knee Hemarthrosis and Achilles Ruptures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Arthroscopy in Acute Traumatic Hemarthrosis of the Knee
F R Noyes, R W Bassett, E S Grood, D L Butler: JBJS, 1980 July; 62 (5): 687
This paper was among the first to identify the high rate of serious knee injuries among patients with acute traumatic hemarthrosis (ATH). Noyes’ paper showed that 72% of knees with ATH also had some degree of ACL injury. While orthopaedists generally no longer use knee arthroscopy as a diagnostic tool in the setting of ATH, because of this article, they often order MRI when patients present with this acute knee injury.

Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures
K Willits, A Amendola, D Bryant, N Mohtadi, J R Giffin, P Fowler, C O Kean, A Kirkley: JBJS, 2010 December 1; 92 (17): 2767
This multicenter randomized trial was not the first to compare surgical treatment of Achilles tendon ruptures with nonoperative treatment that included early functional range of motion, but it confirmed that in patients treated nonoperatively, early functional treatment is preferable to cast immobilization. Since this paper was published, more than 20 studies investigating Achilles tendon ruptures have been published in JBJS, emphasizing that the search goes on for treatment protocols—surgical and nonoperative—that are effective and relatively free of complications.