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.
Up to 33% of patients are dissatisfied with their outcome after a knee or hip replacement. It’s evident that successful recovery from lower-limb joint replacement is aided by leg strength and stamina, but handgrip strength has been proposed as a proxy for a person’s overall muscle strength. A recent prospective cohort study1 of 226 patients who underwent total hip arthroplasty (THA) and 246 patients who underwent total knee arthroplasty (TKA) investigated the association between handgrip strength measured preoperatively with a dynamometer and changes in preoperative versus 1-year postoperative patient-reported outcome scores. Researchers analyzed the data after adjusting for sex, body mass index, and baseline scores.
For both THA and TKA patients, handgrip strength was positively associated with most physical function, symptom, and quality-of-life scores measured with HOOS, KOOS, and SF-36 questionnaires. On the other hand, there was no association between grip strength and mental-component scores in either the THA or TKA group.
Based on a review of the literature and this study’s findings, the authors conclude that the association between handgrip strength and THA/TKA outcomes is partly dependent on the joint site. Although the mechanism to explain the association has not been elucidated, translating these findings into an informal dynamometer-based tool could help clinicians counsel prospective joint-replacement patients about the value of preoperative conditioning.
1. Meessen JMTA, Fiocco M, Tordoir RL, Sjer A, Verdegaal SHM, Slagboom PE, Vliet Vlieland TPM, Nelissen RGHH. Association of handgrip strength with patient-reported outcome measures after total hip and knee arthroplasty. Rheumatol Int. 2020 Apr;40(4):565-571. doi: 10.1007/s00296-020-04532-5. Epub 2020 Feb 18. PMID: 32072233
Time is an enemy of all orthopaedic implants, just as it is the bane of native joints. It is therefore helpful to accurately measure how long and well specific implant types last. That is what Kim et al. have done with their 19-year follow up of 90 patients (107 knees) who underwent total knee arthroplasty (TKA) with a constrained condylar knee prosthesis. Their findings appear in the April 15, 2020 issue of The Journal of Bone & Joint Surgery.
Knee arthroplasty surgeons often choose constrained prostheses to improve joint stability in patients with ligament dysfunction, and the typically longer stems of these implants can also compensate for poor bone stock. Kim et al. evaluated the same patient population (mean age of 65 years; mean BMI of 26.9 kg/m2) that they reported on in an earlier study, finding the following outcomes after a mean follow-up of 19 years:
- 96% survival in terms of mechanical failure
- 91% survival in terms of reoperation for any reason
- Patient-reported outcome scores that remained significantly improved from pre-revision values
- Only 1 knee with osteolysis around a component
Among the few knees that required re-revision, 5 such operations were performed due to aseptic loosening and 4 due to infection. The authors note that these very good long-term results are similar to those in previous studies of revision TKAs using various implant types. Kim et al. attribute these findings to several possible factors:
- Low prevalence of comorbidities, including obesity, among the patients
- Excellent surgical technique, including good cementing and correct flexion and extension gaps
- Use of compression-molded polyethylene
Because of government mandates prohibiting elective surgeries, surgical specialties have been among the hardest hit economically during the COVID-19 pandemic. To reduce overhead, some orthopaedic practices have terminated or furloughed staff or implemented steep pay cuts. But as Powell et al. explain in the latest JBJS fast-tracked COVID-19 article, the pandemic presented a unique opportunity for Orthopedic Physicians Alaska (OPA)–a private, vertically integrated practice based in Anchorage–to transform itself, serve its community, and keep its staff employed and the practice afloat.
Alaska shut down elective surgeries in response to COVID-19 on March 19, 2020, and a statewide stay-at-home order was issued on March 22. While OPA leaders confronted the fact that, under those conditions, the practice would not be financially viable after June 15, the Municipality of Anchorage presented a partnership opportunity to OPA and other local healthcare entities.
Anchorage has a disproportionately large population of homeless people. On any given day in the city of 300,000, the number of shelter beds available is >400 short of meeting the demand. To help prevent COVID-19 deaths on a tragic scale among the homeless, the city emergently created temporary shelters, most of them, apropos of Alaska, in de-iced ice rinks.
But the number of available healthcare workers to staff those facilities was insufficient, so the municipality asked OPA and the other larger healthcare practices in the city whether they’d be willing to provide workers to support both existing and new shelters for the homeless. The proposed tasks were definitely not orthopaedic in nature, Powell et al. report. They included creating workflows for COVID-19 screening, establishing logistics for COVID-19 testing, and providing around-the-clock medical oversight at the isolation and quarantine facilities.
OPA said “yes.” With only days until shelter screening was set to commence, the staff and executive team went into full training mode. Meanwhile, contracts were signed with the city for OPA to be paid an hourly rate compatible with Federal Emergency Management Agency reimbursement for services provided. The surgeons in the practice agreed to assume all clinical orthopaedic duties so physician assistants and other clinical staff could serve at the shelters (see photo above).
OPA transformed an orthopaedic practice delivering musculoskeletal care to a focused COVID-19 healthcare entity within 5 days–while avoiding any furloughs. OPA staff are now screening 1,400 homeless and vulnerable individuals daily. Although the work is neither glamorous nor within the scope of a normal orthopaedic practice, the authors conclude that “cooperation with the Municipality of Anchorage has helped to flatten the curve for the community [and] keep the most vulnerable population safe.”
By definition, a pandemic is a global public health crisis. Consequently, along with reports from North American orthopaedists, JBJS fast-tracked COVID-19 coverage has included data from Singapore, China, Italy, and Portugal. The most recent report, authored by Askari et al., comes from Iran.
Iran announced its first report of COVID-19 on February 19, 2020. As of April 21, 2020, the country had >83,505 documented cases, and the Iranian Ministry of Health (MoH) had reported at least 3,739 deaths from the virus.
Two weeks after the detection of the first COVID-19 cases in Iran, the MoH sent an official letter to all health-care centers—governmental and private—to stop all elective surgeries. Some private-sector hospitals obtained permission to restart elective surgeries, but orthopaedic departments at all governmental healthcare centers saw and treated only trauma patients. Ironically, with self-quarantining in Iran, the number of traffic-related trauma cases has decreased because fewer people are commuting.
Within 1 month after the first official reports of COVID-19 in Iran, most private-sector hospitals completely stopped all their surgeries, and some started seeing patients online. All empty hospital beds were designated for the treatment of patients with COVID-19.
While most orthopaedic surgeons were sidelined from the operating room, the Iranian Orthopaedic Society (IOS) and its branches created multiple social media groups to maintain an open channel for the exchange of scientific ideas and to promote orthopaedic research. Meanwhile, orthopaedic residents, somewhat demoralized because of the cancellation of classes and hospital grand rounds, maintained a level of practical education through trauma surgeries and seeing patients in the emergency department.
The Iran University of Medical Sciences in Tehran is now holding online orthopaedic webinars to maintain orthopaedic education for residents and to exchange up-to-date information regarding COVID-19. In addition, the IOS and its subspecialty divisions have further maintained their case studies using e-learning platforms. However, there are large disparities across the country and among universities in the development and implementation of distance-learning programs.
Overall, Askari et al. concur with orthopaedic surgeons elsewhere in the world that the pandemic has shown that the role of orthopaedists can—and at times must—go far beyond “only tending to fractures.”
In response to the COVID-19 pandemic, an abundance of clinical orthopaedic information has been disseminated in a short period of time. Some of that has been compiled and commented upon here in OrthoBuzz.
On April 12, 2020, the editors of OrthoEvidence, led by Mohit Bhandari, MD, published a report of global recommendations that puts forth evidence-based principles to guide musculoskeletal care in the face of the coronavirus pandemic. The carefully referenced, 65-page report identifies pandemic-related best practices in outpatient care, elective procedures, urgent/emergent procedures, and peri-/postoperative care.
Nearly three-quarters of the 72 publications analyzed for the report were based on expert opinion and/or clinical experience; just over one-quarter were developed using evidence-based methods alone or a combination of evidence-based methods plus expert opinion. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, the report’s authors assign strength ratings for all the recommendations compiled in the review.
The detailed information is best digested from the report itself, but here is a summary of the report’s overarching recommendations for orthopaedic management at this time:
- Ensure patient and staff safety.
- Stay up-to-date about evolving clinical guidelines and your institution’s capacity issues.
- Prevent unnecessary use of personal protective equipment and make contingency plans for supply shortages.
- Schedule only urgent or emergent surgical cases.
- Perform only operative interventions that can be expected to have superior outcomes relative to nonoperative management.
- Convene teams to make decisions about definitive management in semi-urgent or controversial cases.
- Prevent unnecessary follow-up visits.
For obvious reasons, the use of telemedicine has surged during the COVID-19 pandemic. If you are wondering what a “virtual” orthopaedic physical exam looks like, Tanaka et al. explain the process in words and images in a recent fast-tracked JBJS article.
At the time they schedule their virtual visit, patients are asked to confirm their audiovisual capabilities, and they receive specific instructions about camera positioning, body positioning, setting, and attire to improve the efficiency of the visit.
Tanaka et al. give step-by-step instructions for virtually evaluating the knee, hip, shoulder, and elbow. They describe how they measure range of motion using a web-based goniometer (see Figure), and they explain how to conduct virtual strength tests for each joint. To enable post-exam follow-up discussions with patients, the authors recommend using “the screen-sharing function that is presumably available on all interactive telehealth platforms.”
The authors acknowledge the limitations inherent in a virtual orthopaedic exam, such as the inability to directly palpate the joint or perform provocative tests. They also admit that the patient population that would potentially benefit the most from televisits—older patients with limited mobility and who are at higher risk for infection during the pandemic—are also those who may have the most difficulty implementing the technology.
The rapid rise of telemedicine in orthopaedics has occurred due to unexpected necessity, but many expect that its widespread use will continue post-pandemic. Tanaka et al. cite future directions for the technology, including the development of validated, modified examination techniques and advancements that will improve interactivity during the physical examination. For now, though, these experience-based guidelines should help orthopaedists optimize the quality and efficiency of their upcoming virtual visits for common musculoskeletal conditions.
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 OrthoBuzz summaries of these “What’s New” articles. This month, co-author Christopher Y. Kweon, MD selected the 5 most clinically compelling findings from the 40 studies summarized in the April 15, 2020 “What’s New in Sports Medicine.”
ACL Graft Choice
—A randomized controlled trial (RCT) comparing bone-tendon-bone autograft, quadrupled hamstring tendon autograft, and double-bundle hamstring autograft for ACL reconstruction in young adults found the following:
- No between-group differences in patient-reported quality-of-life scores at 5 years
- Significantly higher rates of traumatic graft reinjuries in the hamstring-tendon and double-bundle groups
- Relatively low (37%) return to preinjury level of activity for the entire population, with no significant between-group differences
Meniscal Repairs with Bone Marrow Venting
—A double-blinded RCT1 of patients with complete, unstable, vertical meniscal tears compared isolated meniscal repair to meniscal repair with a bone marrow venting procedure (BMVP). Meniscal healing, as assessed with second-look arthroscopy at a mean of 35 weeks, was 100% in the BMVP group and 76% in the control group (p = 0.0035). Secondary pain and function measures at 32 to 51 months were also better in the BMVP group.
Rotator Cuff Repair Rehab
—A multisite RCT2 among >200 patients who received arthroscopic repair of a full-thickness rotator cuff tear compared standard rehabilitation (patients wore a sling at all times except when performing prescribed exercises) and early mobilization (patients wore a sling only when needed for comfort). Early mobilizers showed significantly better forward flexion and abduction at 6 weeks, but no subjective or objective differences (including retear rate) were found at any other time points.
Remplissage for Anterior Shoulder Instability
—A systematic review3 of studies investigating arthroscopic Bankart repair with and without remplissage found significantly higher instability-recurrence rates with isolated Bankart repair. Overall, the addition of remplissage appears to yield better patient-reported function scores compared with isolated Bankart repair alone.
Syndesmotic Ankle Injuries
—A meta-analysis of 7 RCTs (335 patients)4 comparing dynamic versus static fixation for syndesmotic injuries of the ankle found that the overall risk of complications was significantly lower in the dynamic fixation group. Reoperation rates were similar in the two groups, but implant breakage or loosening was reduced with dynamic fixation devices. Compared with static fixation, the dynamic fixation group also had higher AOFAS scores and lower VAS scores at various time points.
- Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy.2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
- Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy.2019 Mar;35(3):749-760.e2.
- Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy.2019 Feb;35(2):617-28. Epub 2019 Jan 3.
- Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med.2019 Jun 12. [Epub ahead of print].
Most elective surgical procedures in the US have been suspended because of the COVID-19 pandemic, but orthopaedic surgeons continue to provide acute care, and some are being recruited to the COVID-19 “front lines.” Available evidence suggests that older individuals are at higher risk for poor outcomes with COVID-19. In addition, >90% of US orthopaedic surgeons are male, which is thought to be another risk factor for COVID-19 severity.
In the latest fast-track JBJS article on COVID-19, Jella et al. considered those facts when making a geospatial map of US orthopaedic surgeons aged 60 years and older (see Figure above). It turns out that 4 states among those with the highest quintile of orthopaedic surgeons ≥60 years of age are also the 4 states most severely affected by COVID-19: New York, New Jersey, California, and Florida.
The authors did not account for comorbid conditions, nor does their data indicate any direct relationship between older orthopaedic providers and their risk of contracting COVID-19. Nevertheless, Jella et al. make the following observations:
- The high proportion of older surgeons in areas of high rates of disease prevalence may increase their susceptibility.
- The risk of fulminant, possibly fatal disease in older orthopaedic surgeons should be considered in the setting of front-line COVID-19 work.
- These findings could provide a rationale for matching of critically limited personal protective equipment to higher-risk providers.
- The 5-zone before-and-after-surgery protocols described by Rodrigues-Pinto et al. “should be heavily considered if older physicians continue to operate in the midst of this crisis.”
- Implementation of telemedicine services will help minimize contact between older providers and infected patients. Also, older orthopaedic surgeons may serve an important role in resident training during this time, with various digital platforms currently available for remote education.
The authors are quick to add that “the present study does not imply that COVID-19 infection among younger providers is in any way less severe or less important,” nor does it “imply that any particular ethical position should be taken.” The authors emphasize that it is up to individual healthcare systems to choose which surgeons are deployed and in what capacity.
We have all come to realize that promising results from lab studies or preclinical trials in animal models do not always translate into meaningful clinical benefits in humans. Yet it is vitally important to perform those human trials to ascertain that knowledge. This is demonstrated by Schemitsch et al. in the April 15, 2020 edition of The Journal. The authors performed a Level I, double-blinded, randomized controlled trial comparing varying doses of romosozumab to placebo in the treatment of older patients with a hip fracture.
Romosozumab is a sclerostin-inhibiting antibody that helps increase bone formation while decreasing resorption. It is indicated to treat osteoporosis in postmenopausal women, in whom the drug has been shown to increase bone mineral density and reduce the risk of fragility fractures. In multiple preclinical studies, romosozumab has increased bone mass and bone strength in rodent osteotomy models, suggesting it might possibly promote fracture healing in people.
In the current study, Schemitsch et al. randomized patients between 55 and 95 years old who had a low-energy hip fracture amenable to internal fixation to receive 3 postsurgical subcutaneous injections of romosozumab at doses of either 70 mg (60 patients), 140 mg (93 patients), or 210 mg (90 patients), or to receive 3 placebo injections (89 patients). The primary end point was the validated “timed Up and Go” (TUG) score. The authors also measured the Radiographic Union Scale for Hip (RUSH) score, and hip pain on a visual analog scale (VAS).
The authors enrolled 325 patients, with 263 (79.2%) reaching the 24-week follow up and 229 (69.0%) reaching the 52-week follow up. They found no statistically significant between-group differences in the TUG, with all patients improving and plateauing at week 20. Similarly, there were no differences between any of the treatment arms in time to radiographic healing, RUSH scores, or VAS. The safety profile of the medication was similar between the 3 romosozumab doses and the placebo.
Romosozumab may increase bone mineral density and reduce the risk of fragility fracture in patients with osteoporosis, but when it comes to helping heal hip fractures, it did not prove to be more advantageous than placebo. This shows, yet again, that what may glitter in animal studies may not necessarily shine like gold in clinical trials with people.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Jaime L. Bellamy, DO.
A majority of patients I see for knee osteoarthritis (OA) want a quick fix. Many would like to skip conservative treatment–activity modification, weight loss, physical therapy (PT), anti-inflammatory medication, and intra-articular steroid injections–and go straight to surgical management. Regarding nonoperative management of knee OA, the most recent AAOS Clinical Practice Guidelines “strongly” recommend that patients participate in PT and “inconclusively” recommend intra-articular steroid injections.1 Yet, in my clinical practice, I confess to typically offering a knee injection first, before PT.
I may change that practice in light of the randomized controlled trial (RCT) by Deyle et al. in the April 9, 2020 issue of The New England Journal of Medicine. The trial compared PT to glucocorticoid knee injections among 156 primary-care knee OA patients within a military health system. The primary outcome measure was the WOMAC score at 1 year. Secondary outcomes included the Alternate Step Test and the Timed Up and Go test.
Seventy-eight patients randomly assigned to each group were included in the analysis. The PT intervention included detailed home-exercise instructions and 8 sessions with a therapist over the initial 4- to 6-week period. Patients could also attend 1 to 3 PT sessions at the 4-month and 9-month reassessments. Knee-injection patients received 1 ml of triamcinolone acetonide (40 mg per milliliter) and 7 ml of 1% lidocaine up to three times in one year.
The mean baseline WOMAC scores were similar between the groups. However, at 1 year, the authors found a mean between-group difference of 18.8 points in WOMAC scores, favoring PT over injections. Secondary outcomes also favored PT over knee injections.
Regardless of this RCTs limitations, such as the lack of reporting on knee-injection techniques, the findings serve as a reminder to orthopaedists to recommend PT as an effective nonoperative treatment option for knee OA. Additionally, our primary care colleagues can use this data to help convince patients with knee OA that they do not need to rush in to see a surgeon.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
- AAOS Clinical Practice Guidelines, Treatment of Osteoarthritis of the Knee, 2nd Edition (2013), http://www.orthoguidelines.org/topic?id=1005, accessed 4/14/2020.