What’s New in Shoulder and Elbow Surgery 2018
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, Robert Tashjian, MD, co-author of the October 17, 2018 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.
Progression of Primary Osteoarthritis
–A study evaluating the relationship between glenoid erosion patterns and rotator cuff muscle fatty infiltration found that fatty infiltration was associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. The authors recommend close observation of patients with B-type glenoids, as the progression of glenoid erosion is more likely in B-type than A-type glenoids.
Perioperative Pain Management
–In a randomized controlled trial of perioperative pain management in patients undergoing primary shoulder arthroplasty, narcotic consumption during the first 24 postoperative hours was similar between a group that received interscalene brachial plexus blockade and a group that received intraoperative soft-tissue infiltration of liposomal bupivacaine. The interscalene group had lower VAS pain scores at 0 and 8 hours postoperatively; both groups had similar VAS pain scores at 16 hours; and the soft-tissue infiltration group had lower pain scores at 24 hours postoperatively.
Rotator Cuff
–In a reevaluation of patients with nonoperatively treated chronic, symptomatic full-thickness rotator cuff tears that had become asymptomatic at 3 months, researchers found that at a minimum of 5 years, 75% of the patients remained asymptomatic.1 The Constant scores in the group that remained asymptomatic were equivalent at 5 years to those who initially underwent surgical repair. While these findings suggest that nonoperative treatment can yield clinical success at 5 years, the authors caution that “individuals with substantial tear progression or the development of atrophy will likely have a worse clinical result.”
–A recent study of the progression of fatty muscle degeneration in asymptomatic shoulders with degenerative full-thickness rotator cuff tears found that larger tears at baseline had greater fatty degeneration, and that tears with fatty degeneration were more likely to enlarge over time. Median time from tear enlargement to fatty degeneration was 1 year. Because the rapid progression of muscle degeneration seems to occur with increasing tear size, such patients should be closely monitored if treated nonoperatively.
Shoulder Instability in Athletes
–An evaluation of outcomes among 73 athletes who had undergone Latarjet procedures found that, after a mean follow-up of 52 months, ASES scores averaged 93. However, only 49% of the athletes returned to their preoperative sport level; 14% decreased their activity level in the same sport; and 12% changed sports altogether. While the Latarjet can help stabilize shoulders in athletes, the likelihood is high that the athlete won’t return to the same level in the same sport after the procedure.
Reference
- Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-8.
Better News for TJA Patients with Depression
Over the last 2 decades, research into how various “preexisting conditions” affect the outcomes of orthopaedic interventions has increasingly focused on the impact of mental health (a patient’s “state of mind” and coping abilities) and psychological diagnoses such as depression. The impact of mental health, depression, and personality characteristics on patient-reported outcomes following significant skeletal trauma has been well documented in the trauma literature. In addition, previous studies in knee arthroplasty have identified depression as a major factor in suboptimal patient outcomes.
In the October 17, 2018 issue of The Journal, Halawi et al. teased out the impact of depression and mental health—independently and in combination—on patient-reported outcomes following primary total joint arthroplasty (TJA) in 469 patients at a minimum follow-up of one year.
The authors used the validated SF-12 MCS instrument to assess patient baseline mental health at the time of surgery. They also used the widely accepted WOMAC score to assess joint-specific pain, stiffness, and physical function before and after surgery. Using these tools, the authors showed that, while depression alone may diminish some patient-reported gains obtained from arthroplasty, it does not seem to affect a patient’s overall outcome as much as poor mental health prior to surgery. In this study, patients with depression but good mental health achieved patient-reported outcomes comparable to those among normal controls. Still, patients without depression and in good mental health were found to have the most robust improvements after undergoing TJA.
Orthopaedic surgeons need to better understand the interplay between these complex psychological states and patient outcomes. These authors conclude that the effect of depression on patient-reported outcomes is “less pessimistic than previously thought,” but we welcome further studies examining the link between “the mind” and orthopaedic outcomes. Finally, we should be ready to refer patients to our mental health colleagues when we detect a potential underlying nonphysical condition that might adversely affect the magnitude of benefit from the treatments we offer.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Less Pain, More Gain with Just One Screw
Image courtesy of AO Surgery Reference
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD in response to a recent study in the Journal of Orthopaedic Trauma.
Low-energy sacral fractures in the geriatric population typically heal over time without operative intervention. Nonoperative treatment usually involves analgesics and progressive rehabilitation. Unfortunately, given the frailty and low physiologic reserves of many in this patient population, these fractures can still take a significant toll. Fracture pain may last for weeks to months; deconditioning occurs secondary to poor mobilization; and many patients are discharged to skilled nursing facilities rather than returning directly home.
Given this associated morbidity, Walker et al.1 asked whether percutaneous transiliac-transsacral screw fixation could offer some benefit in the treatment of sacral fragility fractures. The authors present a retrospective review of 41 elderly patients who were admitted with sacral fragility fractures. All patients first received a trial of nonoperative management, which included analgesia and physical therapy-guided mobilization. If patients were unable to appropriately ambulate secondary to pain, they were offered surgery. Sixteen patients elected surgery, which consisted of transiliac-transsacral screw fixation of the posterior pelvic ring.
After surgery, the operative group reported greater reductions in pain than the nonoperative cohort, and they were more likely to be discharged directly home from the hospital (75% versus 20%). Furthermore, at the time of discharge, 100% of the surgical patients were able to ambulate with physical therapy, compared to only 72% of the nonoperative group. No surgical complications occurred, and the average total surgical time was only 34 minutes.
Sacral fragility fractures can result in significant pain and disability in an already frail population. While these fractures are typically managed conservatively, this study suggests that some patients may benefit from surgical intervention. Percutaneous transiliac-transsacral screw fixation is a relatively low-risk procedure (at least in the normomorphic sacrum). And if a single screw can reduce pain, improve function, and more quickly return geriatric patients to their baseline level of independence, then the risk-benefit calculus would favor surgery, unless specific contraindications are present.
While this study is not powerful enough to rewrite treatment protocols, it does give credence to considering surgical fixation for sacral fragility fractures in those who still struggle after a trial of conservative management, and it makes a strong argument for further investigation.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Reference
- Walker, J. Brock, et al. “Percutaneous Transiliac–Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home.” Journal of orthopaedic trauma 32.9 (2018): 452-456.
JBJS 100: Epiphyseal Plate Injuries, Spinal Osteomyelitis
Under 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 full-text 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:
Injuries Involving the Epiphyseal Plate
RB Salter, WR Harris: JBJS, 1963 April; 45 (3): 587
In addition to presenting the fracture classification, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then explain how physeal damage may arise from misalignment, crushing, or vascular interruption. This enduring orthopaedic schema lives on because of its clarity of presentation and its implications for treatment.
Pyogenic Osteomyelitis of the Spine
J Kulowski: JBJS, 1936 April; 18 (2): 343
In this 22-page analysis and discussion of 102 cases, the author notes that pyogenic osteomyelitis of the spine can affect any part of the vertebral system. In 1936—8 years after the discovery of penicillin—Kulowski said, “It may be axiomatically stated that operative intervention is imperative, as soon as the diagnosis is made with a reasonable degree of accuracy, when suppuration is present…,” adding that “the primary spinal focus requires the first attention of the surgeon.”
October 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.”
This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.
Team Physicians Finally Get Federal Licensing and Liability Protection
When it comes to passing federal legislation on Capitol Hill, common-sense solutions for relatively straightforward problems are often not easy to come by. There always seems to be something holding up every piece of legislation, no matter how great the benefits and how minimal the risks/costs.
That is why I was happy to hear that Congress passed the Sports Medicine Licensure Clarity Act earlier this month. The legislation clarifies that health care services provided by a licensed provider in a state other than the one in which he/she is licensed (a scenario commonly encountered by physicians and athletic trainers who travel with collegiate or professional athletic teams) will be considered in-state services and will be covered by the provider’s liability insurance.
The American Association of Orthopaedic Surgeons (AAOS) and several other provider groups—including the American Orthopaedic Society for Sports Medicine (AOSSM)—have long recognized that previous laws exposed many team physicians to medical liability if they provided care in states in which they did not have a medical license. The Clarity Act protects orthopaedic surgeons, athletic trainers, and other health care professionals who serve as traveling care providers from licensure hassles and potential liability so they can focus on caring for their athlete-patients.
As someone who has been engaged in orthopaedic advocacy efforts for my entire, albeit short, orthopaedic career, I am proud of this accomplishment. Advocacy is not for the faint of heart, and the amount of work that goes on behind the scenes to get legislation like this enacted is astounding. Arguably, such efforts have never been more important than they are in today’s health care environment. If we, as orthopaedic surgeons, do not advocate on behalf of our patients and ourselves, no one else will.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Cost Analysis of Treatments for Unicompartmental Knee Arthritis: UKA Wins
Surgical treatment for knee osteoarthritis (OA) has become increasingly common. The many people who have damage to only one part of their joint (unicompartmental knee OA) are faced with three options—total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or nonsurgical treatment. A study by Kazarian et al. in the October 3, 2018 issue of The Journal estimates the lifetime cost-effectiveness for those three options in patients from 40 to 90 years of age.
The authors used sophisticated computer modeling to estimate both direct costs (those related to medical/surgical care) and indirect costs (such as missed workdays) of the three options as a function of patient age at the time of treatment initiation. Here are the key findings:
- The surgical treatments were less expensive and provided patients from 40 to 69 years of age with a greater number of quality-adjusted life years (QALYs) than nonsurgical treatment.
- In patients 70 to 90 years of age, surgical treatments were still cost-effective compared with nonsurgical treatment, albeit less so than in younger patients. In this older age group, “cost-effectiveness ratios” of surgical treatment remained below a “willingness to-pay” threshold of $50,000 per QALY.
- When the two surgical treatments were compared to one another, UKA beat TKA decisively in cost-effectiveness among patients of any age.
After crunching more numbers, Kazarian et al. estimated that, by 2020, if all of the patients with unicompartmental knee OA who were candidates for UKA or TKA (a projected total of 120,000 to 210,000 people) received UKA, “it would lead to a lifetime cost savings of $987 million to $1.5 billion.
From these findings, the authors conclude that patients with unicompartmental knee OA should receive surgical treatment, preferably UKA, instead of nonsurgical treatment until the age of 70 years. After that age, all three options are reasonable from a cost-effectiveness perspective.
But perhaps the most important thing to remember about these findings is that they add information to—but should not replace—clinical decision-making based on complete and open communication between doctor and patient.
New Isn’t Always Better
Diagnosing acute compartment syndrome (ACS) is challenging. The signs and symptoms of ACS are easy to conflate with those of the overall musculoskeletal injury; the treatment, fasciotomy, is not without risks; and the consequences of delaying or missing the diagnosis altogether can be catastrophic. It is for these reasons that the notion of a device that can continuously monitor a wounded extremity for ACS and alert surgeons when intervention should be considered is so appealing. Yet, as the study by Schmidt et al. and the METRC group in the October 3, 2018 JBJS suggests, the ideal and reality are not aligned.
In this prospective blinded study, the authors evaluated the ability of near-infrared spectroscopy (NIRS) sensors and intramuscular pressure (IMP) catheters to monitor the tissue oxygen-saturation and compartment pressures, respectively, of patients who sustained an injury that is associated with the development of compartment syndrome. They found that clinically useful NIRS data was available only about 9% of the time, whereas IMP information was available >85% of the time. Certain injury characteristics (such as fractures associated with hematomas) made obtaining data with the NIRS especially difficult.
While these results don’t bode well for NIRS as a reliable ACS monitoring tool, it should be noted that the users of the NIRS system in the study were mostly unaware of when the NIRS system was not collecting clinically useful data in real time. Obviously, you can’t correct a problem if you don’t know it exists, and it is possible the results of the study would have been different if NIRS users were able to troubleshoot the system when data were not being captured. Still, after reading this article, it seems difficult to justify using NIRS to monitor a patient for development of ACS.
New diagnostic tools and techniques are always being developed, and we should remember the results of this study when any “new-fangled” device enters the clinical landscape. A test’s most important feature is its ability to reliably provide clinically useful data to aid in decision-making. If it cannot do so, it is simply providing distracting ”noise” from which misinterpretations can be made.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Activities that Patients—and their PTs—Should Avoid After THA
The adult joint-reconstruction community has made great strides in the last 2 decades in understanding what causes aseptic loosening of arthroplasty components. For example, revelations about polyethylene particulate debris has led to the production of highly cross-linked polyethylene, which in turn has lowered wear rates, decreased revision rates, and increased the survivorship of total hip implants (see related OrthoBuzz post). Still, polyethylene debris is only one factor that can lead to aseptic loosening. Another important, yet often overlooked, factor is friction between the impacted acetabular shell and the host bone.
In the October 3, 2018 issue of The Journal, Bergmann et al. report data that help us better understand the “friction factor” in aseptic loosening. The authors implanted specially designed, instrumented acetabular components that measured in vivo friction moments among nine patients while they engaged in >1,400 different activities. The authors found that 124 of those activities led to friction moments >4 Nm—which appears to be the upper limit for facilitating a firm union between the acetabular component and the native socket.
Movements such as muscle stretching in the lunge position, the breaststroke in swimming, 2-legged standing with muscles contracted, and a single-legged stance while moving the contralateral leg were among those that created the highest friction between the implant and the host bone—and that could impede bone ingrowth into the acetabular component and thus contribute to aseptic loosening. The study also highlights the importance of periodic unloading of the prosthetic joint to allow proper synovial lubrication, which helps minimize the effects of high-friction moments. The good news is that the vast majority of activities studied do not appear to result in friction forces above the 4 Nm threshold.
Although these data should be confirmed with other in-vivo instrumented prostheses (assuming there are more patients willing to receive acetabular components capable of delivering telemetric data), they provide practical insight into the real-world forces placed on total hip prostheses after implantation. Such information can be used to counsel patients regarding high-friction and sustained-loading activities to be avoided, and it can help physical therapists and surgeons tailor postoperative regimens that optimize patient recovery while minimizing the risk to implanted prostheses.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS 100: Approach to the Lumbar Spine, Knee Flexion Contracture
Under 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 full-text 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 Paraspinal Sacrospinalis-Splitting Approach to the Lumbar Spine
LL Wiltse, JG Bateman, RH Hutchinson, WE Nelson: JBJS, 1968 July; 50 (5): 919
In this classic 1968 JBJS paper, Wiltse and co-authors described a novel and innovative access route to the lumbar spine. Advantages included reduced blood loss, less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments. The Wiltse approach still represents one of the main access routes to the lumbar spine.
Treatment of Knee Flexion Contracture Due to Central Nervous System Disorders in Adults
JN Martin, R Vialle, P Denormandie, G Sorriaux, H Gad, I Harding, O Dizien, T Judet: JBJS, 2006 April; 88 (4): 840
To address what was at the time a lack of interest among orthopaedic surgeons in treating spasticity in adults, these authors expanded upon earlier work studying the treatment of knee flexion contractures in this population. Their procedure included distal hamstring lengthening, a posterior capsulotomy in some of the knees, and use of a unilateral external fixator in most of the knees. Mean flexion contracture improved from a mean of 69° preoperatively to a mean of 6.2° at 1 to 5 years after surgery.
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