Archive | July 2019

Delaying Knee Replacement: Driven to Distraction?

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.

Some symptomatic patients with knee osteoarthritis (OA) present relatively early in the radiographic disease process, while others present after serious articular cartilage loss has occurred. In either case, young knee OA patients are often looking for ways to get relief while postponing a total knee arthroplasty (TKA).

One such recently introduced alternative is knee joint distraction (KJD), a joint-preserving surgery used for bicompartmental tibiofemoral knee osteoarthritis or unilateral OA with limited malalignment. Significant long-term clinical benefit as well as durable cartilage tissue repair have been reported in an open prospective study with 5 years of follow-up.1 A more recent study of distraction2 presents 2-year follow-up results of a 2-pronged trial that measured patient-reported outcomes, joint-space width (JSW), and systemic changes in biomarkers for collagen type-II synthesis and breakdown.

In one arm, end-stage knee OA patients who were candidates for TKA were randomized to KJD (n=20) or TKA (n=40). In the second arm, earlier-stage patients with medial compartment OA and a varus angle <10° were randomized to KJD (n=23) or high tibial osteotomy (HTO; n=46). In the distraction patients, the knee was distracted 5 mm for 6 weeks using external fixators with built-in springs, placed laterally and medially, and weight-bearing was encouraged. WOMAC scores and VAS pain scores were assessed at baseline and at 3, 6, 12, 18, and 24 months.

At 24 months, researchers found no significant differences between the KJD and HTO groups in that part of the trial. In the KJD/TKA arm, there was no difference in WOMAC scores between the two groups, but VAS scores were lower in the TKA group. The improvement in mean joint space width seen at one year in the KJD group of the KJD/TKA arm decreased by two years, though the values were still improved compared to baseline. However, the joint space width improvement seen at 1 year for both groups in the KJD/HTO arm persisted for two years. For all KJD patients, the ratio of biomarkers of synthesis over breakdown of collagen type-II was significantly decreased at 3 months but reversed to an increase between 9 and 24 months.

It is hard to believe that 6 weeks of joint distraction could trigger a process that yields such positive and long-lasting results. While much more research with longer follow-up is needed, KJD may prove particularly useful in younger knee OA patients trying to delay joint replacement.

References

  1. van der Woude, JAD, Wiegant, K, van Roermund, PM, Intema, F, Custers, RJH, Eckstein, F. Five-year follow-up of knee joint distraction: clinical benefit and cartilaginous tissue repair in an open uncontrolled prospective study. Cartilage. 2017;8:263-71.
  2. Jansen MP, Besselink NJ, van Heerwaarden RJ, Roel J.H. Custers1, Jan-Ton A.D. Van der Woude J-TAD, Wiegant K, Spruijt S, Emans PJ, van Roermund PM, Mastbergen SC, Lafeber FP. Knee joint distraction compared with high tibial osteotomy and total knee arthroplasty: two-year clinical, structural, and biomarker outcomes. ORS 2019 Annual Meeting Paper No. 0026 (Cartilage. 2019 Feb 13:1947603519828432. doi: 10.1177/1947603519828432. [Epub ahead of print])

“True Grit” Among Millennial Orthopaedists in Training

In a survey-based study published in the July 17, 2019 issue of The Journal of Bone & Joint Surgery, Samuelsen et al. made a hypothesis arising from a popularly held assumption about millennials: that orthopaedic residency applicants (predominantly millennials, with a mean age of 27.3) would have lower grit and self-control scores than attending orthopaedic surgeons (mean age of 51.3). The findings contradicted that hypothesis.

Surveys were completed by 655 (28%) of 2,342 attendings who received the questionnaire and by 455 (50.8%) of 895 orthopaedic residency applicants from the 2016-2017 resident match. The authors found that the residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p <0.01). When compared to the general population, residency applicants and attendings scored in the 70th and 65th percentiles of grit, respectively.

The American Heritage Dictionary defines “grit” as “indomitable spirit” or “pluck.” In the medical literature, where “grit” has received a lot of attention lately, the concept is defined as “steadfast passion and perseverance for long-term goals, especially in the setting of hardship and setbacks.” However grit is defined, Samuelson et al. say it “has consistently been proven to be associated with success in…medical environments.”

Three other interesting findings:

  • There were no significant differences in self-control or conscientiousness scores between the 2 groups.
  • Both age and number of years in practice were positively correlated with self-control scores in the practicing-surgeon group.
  • Among attending surgeons, the number of publications correlated with higher grit, self-control, and conscientiousness scores.

Samuelson et al. offer a possible explanation for the impressive grit scores among residency applicants: matching into orthopaedic residency has become increasingly competitive over the past several decades and “applicants to orthopaedic surgery…tend to represent the individuals at the top of their medical school classes.” Conversely, the authors suggest that grit, self-control, and conscientiousness scores could be used to identify applicants, residents, or junior staff “who are at risk for attrition during training or burnout in their careers.”

Having postulated that, however, the authors are quick to add that “it is unclear if [these findings] will be predictive of career success in the next generation of orthopaedists.”

Click here to see a 1-minute video commentary about these findings by Chad A. Krueger, MD, JBJS Deputy Editor for Social Media.

Study Supports Routine Patellar Resurfacing during TKA

The July 17, 2019 issue of The Journal features another investigation evaluating patellar resurfacing. Despite much research (see related OrthoBuzz post), this topic remains controversial among many total knee arthroplasty (TKA) surgeons. This study, by Vertullo et al., analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry. The findings suggest that routine resurfacing of the patella reduces the risk of revision surgery for TKA patients.

The authors evaluated more than 136,000 TKA procedures after placing the cases into three groups based on the surgeon’s patellar-resurfacing preference: infrequent (<10% of the time), selective (10% to 90% of the time), or routine (≥90% of the time). All of the cases evaluated utilized minimally stabilized components and cemented or hybrid fixation techniques, and they all were performed by surgeons who completed at least 50 TKAs per year.

The authors found that patients in the infrequent-resurfacing cohort had a nearly 500% increased risk of undergoing subsequent patellar revision during the first 1.5 years after TKA, compared to those in the routine-resurfacing cohort. Even more surprising to me was the finding that patients in the selective-resurfacing cohort had a >300% increased risk of needing a patellar revision within the first 1.5 years, compared to those in the routine-resurfacing cohort. In addition, the risk of all-cause revision was 20% higher in the selective cohort compared to the routine cohort.

What struck me most about this study were the differences between the selective and routine cohorts. One of the arguments against routine resurfacing of the patella is that surgeons should decide intra-operatively, on a patient-by-patient basis, whether the osteochondral health and biomechanics of the native patella warrant resurfacing. The findings of Vertullo et al. seem to call that reasoning into question. Although the results of this study add to the evidence supporting the routine resurfacing of the patella during TKA, I would like to reiterate a proviso from my earlier post on this topic: resurfacing is associated with added costs and an increased risk of potential complications.

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

New Minute-Commentary Video

Here’s what JBJS Deputy Editor for Social Media Chad Krueger, MD concludes after reading a survey-based study from the Department of Orthopaedic Surgery at the Mayo Clinic, comparing “grit” and self-control among orthopaedic residency applicants and practicing orthopaedists:

 

Why US Orthopaedic Residents Overprescribe Opiates

Hydrocodone Has Dark Side as Recreational DrugSeveral authors have described the medical-school experience as “socialization” into the medical field. Medical students often learn the scientific underpinnings simultaneously with the social processes of interviewing/dialoging, examining, and then developing a treatment plan with the patient. One “subspecialty” social process that orthopaedists learn is pain management. While we are certainly encouraged to understand the scientific basis of this important and complex topic, much of the learning comes in the form of mirroring: junior residents do what senior residents instruct them to do, while senior residents follow the direction of attendings. These passed-on habits are culturally ingrained and persistent.

As Young et al. show in the July 17, 2019 issue of The Journal, the pain-management habits learned in training vary greatly from country to country, which is not surprising. Specifically, these authors examined the prescribing of postprocedural opiates by residents in the Netherlands, Haiti, and United States. They found that US residents prescribe significantly more morphine milligram equivalents (MMEs) of opioids at patient discharge than residents from either of the other 2 countries. The authors also showed that residents from the United States were the only group prescribing a significantly greater amount of MMEs to patients younger than 40 years old than to those above the age of 70.

Many pundits pin the phenomenon of opioid overprescribing in the US on the American public’s wish to be free from discomfort, along with the aggressive marketing and advertising of these medications in the United States. While this may be true, I think Young et al. have further identified the major influence that a resident’s training environment may have on prescribing practices. As already mentioned, residents often imitate what they see from more experienced residents and attendings, but sometimes those lessons, especially in pain management, lack a scientific basis.

What is missing from this survey-based study is data on patient satisfaction with postprocedural opiate prescribing. Having been involved in clinical care in Haiti, my impression is that patients there accept the local practice of pain management, constrained as it might be by resource limitations. I suspect the same is true in the United States and the Netherlands. Regardless, these findings demand that emphasis be placed on teaching orthopaedic residents evidence-based pain-management protocols. This will require a concerted effort from teachers and mentors at all levels of our medical-education system. This investigation is an important reminder that developing solutions to the opioid overprescribing problem in the US might begin in residency, where “cultural formation” occurs.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Orthopaedic Trauma 2019

Every month, JBJS publishes 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 25 noteworthy studies summarized in the July 3, 2019 What’s New in Orthopaedic Trauma” article.

Proximal Humeral Fractures in the Elderly
–A recent meta-analysis1 analyzing data from >1,700 patients older than 65 who experienced a proximal humeral fracture found no difference in Constant-Murley scores at 1 year between those treated operatively (most with ORIF using a locking plate) and those treated nonoperatively. There was also no between-group difference with respect to reoperation rates among a subgroup of patients from the 7 randomized trials examined in the meta-analysis.

Elbow Dislocation
–A study using MRI to evaluate soft-tissue injuries in 17 cases of “simple elbow dislocation”2 found that the most common soft-tissue injury was a complete tear of the anterior capsule (71% of cases), followed by complete medial collateral ligament (MCL) tears (59%) and lateral collateral ligament tears (53%). These findings challenge previous theories positing that elbow instability starts laterally, with the MCL being the last structure to be injured.

Pertrochanteric Hip Fractures
–A trial randomized 220 patients with a pertrochanteric fracture to receive either a short or long cephalomedullary nail.3 There were no significant differences between the 2 groups at 3 months postsurgery in terms of Harris hip and SF-36 scores, but patients treated with the short nail had significantly shorter operative times, less blood loss, and shorter hospital stays. The incidence of peri-implant fractures between the 2 devices was similar.

 Ankle Syndesmosis Injuries
–A randomized trial involving 97 patients with syndesmosis injuries compared functional and radiographic outcomes between those treated with a single syndesmotic screw and those treated with suture-button fixation. At 6 months, 1 year, and 2 years after surgery, patients in the suture-button group had better AOFAS scores than those in the screw group. CT scans at 2 years revealed a significantly higher tibiofibular distance among the screw group, an increase in malreduction that was noted only after screw removal. That finding could argue against early routine syndesmotic screw removal.

Infection Prevention
–A randomized trial among 470 patients4 facing elective removal of hardware used to treat a below-the-knee fracture compared the effect of intravenous cefazolin versus saline solution in preventing surgical site infections (SSIs). The SSI rate was surprisingly high in both groups (13.2% in the cefazolin group and 14.9% in the saline-solution group), with no statistically significant between-group differences. The authors recommend caution in interpreting these results, noting that there may have been SSI-diagnosis errors and that local factors not applicable to other settings or regions may have contributed to the high SSI rates.

References

  1. Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH,Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg.2018 Aug;27(8):1526-34. Epub 2018 May 4.
  2. Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg.2019 Feb;28(2):341-8. Epub 2018 Nov 8.
  3. Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
  4. Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED,Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI,Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. 2017 Dec 26;318(24):2438-45.

Step Monitors Yield New Insight into Ankle Surgery Outcomes

Patients considering surgery for end-stage ankle arthritis often ask which  treatment—arthroplasty or arthrodesis—will help the most. Findings from various studies attempting to answer that complex question have been equivocal. In the July 3, 2019 issue of The Journal of Bone & Joint Surgery, Shofer et al. inject some objective data gleaned from step counters worn by 234 patients into this predominantly subjective question.

All patients were treated with either arthroplasty (n = 145) or arthrodesis (n = 89). Their step activity was measured with a StepWatch 3 Activity Monitor preoperatively and at 6, 12, 24, and 36 months postoperatively. In both groups combined, step counts during “high activity” (>40 steps per minute) increased by 46% over 36 months. At 6 months, the mean high-activity step improvement was 194 steps in the arthroplasty group, compared with a mean decline of 44 steps for the arthrodesis group. However, by 36 months after surgery, the between-group differences in high-activity steps had disappeared.

The authors also analyzed associations between the objective step results and 3 patient-reported outcomes (the Musculoskeletal Function Assessment and the SF-36 physical function and pain scores). Unlike the patient-reported scores, which improved dramatically in the first 6 months and then plateaued, improvements in step activity increased gradually throughout the 3-year follow-up.

The authors emphasized that during the first 12 postoperative months, the arthrodesis patients had little or no improvement in step activity, but at 3 years there were no significant differences between arthrodesis and arthroplasty patients. These findings suggest that, in this clinical scenario, an individual patient’s expectations with the pace of improvement may be a suitable topic during shared decision making conversations.

This study does not entirely reconcile previously equivocal findings regarding arthroplasty-versus-arthrodesis, but it does emphasize the substantial and sustained activity benefits that patients in both groups receive. Shofer et al. conclude that objective measurements from wearable technology “may complement patient-reported outcomes” in future longitudinal outcome studies of many orthopaedic treatments.

July 2019 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 July 2019, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial.”

Among 103 patients with plantar heel pain who received either arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection, the injection was more effective at week 4, but the foot orthoses were more effective at  week 12. But the authors note that “the differences between the interventions did not meet the previously calculated minimal [clinically] important difference value of 12.5 points.”

With or Without Cement, Results with Triathlon TKA Are Same after 2 Years

With the increasing frequency of total knee arthroplasty (TKA) surgeries and the ever-increasing implant options available to orthopaedists for these cases, it is important that we carefully analyze new devices and technologies. We have already seen too many instances in which the enthusiasm for (and use of) a new implant outpaced the evidence for its efficacy and safety, leading to problems for patients, surgeons, and manufacturers alike.

The results of the randomized trial by Nam et al. in the July 3, 2019 issue of The Journal start to tackle this issue. The authors compared operative times, patient outcomes, and radiographic measures between patients who received either a recently introduced cementless or traditionally cemented cruciate-retaining TKA implant of the same design (the Triathlon TKA implant from Stryker). They found no clinically meaningful or statistically significant differences between the two groups in terms of Oxford Knee Score or Knee Society Score at any point during the average 2-year follow-up. In addition, nearly equal percentages of patients in each group reported being “extremely” or “very” satisfied with their functional outcome at 2 years, and radiographically, the researchers found no significant difference between the groups in terms of radiolucency behind the tibial or femoral implants. The one notable between-group difference was operative time, with the cementless cohort having a mean surgical time roughly 11 minutes less than that of the cemented cohort.

These results are encouraging in that they show improved operative efficiency with none of the aseptic loosening that has historically been a concern with cementless knee implants. Still, the authors make it clear that “the burden of proof remains with cementless fixation,” largely because cementless implants cost more than their cemented counterparts. Those higher costs need to be justified by improved outcomes (including implant survivorship), decreased complications, or both in order for cementless implants to displace cemented ones as the “standard of care.”

We are not there yet,  but the findings from Nam et al. justify further surveillance of this cementless device. Future high-quality studies incorporating joint registry data and longer patient follow-up will hopefully provide the supporting evidence with which the joint-arthroplasty community can decide whether this relatively new cementless technology should be the implant of choice for certain  patient populations.

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

More Mortality Data on Hip Fractures in the Elderly

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.

Among the elderly, low-energy hip fractures are common injuries that almost all orthopaedic surgeons encounter. While operative management is typically the standard of care, there are some patients for whom nonoperative treatment is most aligned with their goals of care, usually because of chronic disease, fragility, and/or high risk of perioperative mortality.

When counseling elderly patients and family members about the risks and benefits of surgical management for a hip fracture, we have abundant data. We can estimate the length of rehabilitation, discuss the likelihood of regaining independence with ambulation, and quote the 30-day, 1-year, and 5-year mortality statistics. But what about the risks and benefits of nonoperative care? How long do these patients live? How many are alive 1 year after the fracture?

Chlebeck and colleagues attempt to answer those questions with a retrospective cohort study of 77 hip fracture patients who were treated nonoperatively and a matched cohort of 154 operatively treated hip fracture patients. Nonoperative management was chosen only after a palliative-care consult was obtained and after a thorough multidisciplinary discussion of treatment goals with the patient and family. Patients who elected nonoperative care were treated with early limited weight bearing and a focus on maximizing comfort. Researchers established a comparative operative cohort through 2:1 matched pairing, controlling for age, sex, fracture type, Charlson Comorbidity Index, preinjury living situation, preinjury ambulatory status, and presence of dementia and cardiac arrhythmia.

As one might expect, there was significantly lower mortality in the operative group. The in-hospital, 30-day, and 1-year mortality for nonoperatively treated patients was 28.6%, 63.6%, and 84.4% respectively. The mortality rates seen in the operative cohort were 3.9%, 11.0%, and 36.4% respectively. A Kaplan-Meier survival analysis revealed the median life expectancy in the nonoperative cohort to be 14 days, versus 839 days in the operative group (p <0.0001). Interestingly, the researchers found no difference in hospital length of stay between the two groups (5.4 vs. 7.7 days; p=0.10).

These results provide useful references for orthopedic surgeons to use when counseling hip fracture patients and their families. Surgical intervention remains the standard of care in most instances, and this study suggests that operative care offers a significant mortality benefit over nonoperative care even in relatively unhealthy patients, like those selected for the matched operative cohort.

This study also gives us data to help guide the expectations of patients who decide surgery is not in line with their wishes. Half of the patients who elected nonoperative care in this study died within 14 days of admission, and only 15.6% were still alive at 1 year. Additionally, choosing nonoperative care does not lengthen hospitalization, suggesting that these patients can be quickly transferred to a more comfortable setting.

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.