Archive | January 2021

JBJS Clinical Classroom: A Better Path to Orthopaedic Proficiency

In 2017, JBJS partnered with NEJM Group to launch JBJS Clinical Classroom—an adaptive learning platform that meets the unique learning needs and requirements of orthopedic training programs worldwide. Clinical Classroom identifies gaps in individual users’ knowledge and assesses their self-confidence in 11 orthopaedic subspecialties. Curated by orthopaedic experts and powered by leading-edge learning technology, Clinical Classroom has quickly become a leading platform for helping orthopaedic residency programs to:

  • Identify residents’ knowledge gaps through detailed reports and monitoring
  • Improve residents’ knowledge and critical thinking skills
  • Keep residents up-to-date with the latest and highest-quality orthopaedic findings
  • Better prepare residents for OITE and board certification exams

To meet changing user needs and implement technological advancements, JBJS has improved the overall user experience in Clinical Classroom. These significant enhancements were made possible by upgrading from the original NEJM Knowledge+ platform to the new Rhapsode platform by Area9.

Highlights of JBJS Clinical Classroom on Rhapsode include the following:

  • Updated adaptive algorithm that incorporates the most advanced adaptive tools for more efficient individualized learning
  • Improved reporting and metrics providing residents and residency directors with a more comprehensive dive into individual and group performance
  • In-platform coaching delivers helpful tips tailored to resident progress and confidence as they progress through subspecialties
  • Enhanced look and feel: The clean, modern Dashboard and improved navigation allow residents to interact with and move effectively throughout the product for optimal learning
  • And so much more

To learn more about the enhanced JBJS Clinical Classroom on Rhapsode and how Clinical Classroom can best serve your program, click here.

T-Scores for Diagnosing Osteoporosis: 3 Are Better Than 1

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 World Health Organization (WHO) and the International Society for Clinical Densitometry (ISCD) define osteoporosis based on (DXA) measures of bone mineral density that are translated into T-scores. A T-score ≤ -2.5 at any 1 of the 3 commonly measured sites (lumbar vertebrae, femoral neck, and total hip) is considered diagnostic for osteoporosis, and a T-score between -2.5 and -1 is indicative of osteopenia. University of Pennsylvania investigators1 proposed that combining all 3 T-scores in a multivariate analysis would be “potentially more informative” than the common practice of using the single lowest T-score.

The investigators applied multivariate statistical theory to T-scores from a sample of 1,000 65-year-old white women. When both real data and simulation models were analyzed, the researchers found that more patients were diagnosed with osteoporosis using the multivariate version of the WHO/ISCD guidelines than with the current WHO/ISCD guidelines. The diagnoses of osteoporosis using this method were also associated with higher Fracture Risk Assessment Tool (FRAX) probabilities of major osteoporotic fractures (P=0.001) and hip fractures (P=2.2×10−6). The FRAX tool combines a patient’s history of fracture with age, sex, race, height, weight, and social habits such as smoking and drinking to determine the risk of a major facture in the next 10 years.

This study shows that statistically considering all 3 T-scores may reveal more cases of osteoporosis than using the single lowest T-score. The trick will be getting this insight into the hands—and minds—of those making radiologic interpretations of DXA findings.

Reference 

  1. Sebro R, Ashok S. A Statistical Approach regarding the Diagnosis of Osteoporosis and Osteopenia from DXA: Are we underdiagnosing osteoporosis? J. Bone Mineral Res Plus. In press

Accuracy of Rapid Alpha Defensin Test Confirmed

In June 2019, OrthoBuzz reported on the FDA approval of a rapid, lateral-flow alpha defensin test that helps detect periprosthetic joint infections (PJIs) from synovial fluid. In the January 20, 2021 issue of The Journal of Bone & Joint Surgery, Deirmengian et al. report findings from the Level II diagnostic-accuracy study that led to this FDA approval.

The authors compared diagnostic sensitivity and specificity of the lateral-flow alpha defensin test with the “gold-standard” PJI diagnostic criteria endorsed by the Musculoskeletal Infection Society (MSIS) in 2013. They made the comparison with 2 groups: a prospective patient cohort of 305 patients with a failed hip or knee arthroplasty (57 of whom were determined by MSIS criteria to have a PJI) and among a “control” cohort of 462 synovial fluid samples (65 of which met MSIS criteria for PJI).

After excluding 17 patients from the prospective cohort who had grossly bloody aspirates, the authors found a sensitivity of 94.3% and a specificity of 94.5% for the lateral-flow test in that group. Among the control cohort, the lateral-flow test’s sensitivity was 98.5% and its specificity was 98.2%. Furthermore, after combining data from the 2 cohorts, Deirmengian et al. found no performance difference between the lateral-flow test (which yields results in 10 to 15 minutes) and the lab-based alpha defensin ELISA test (which typically yields results in 24 hours). Finally, in a nonstatistical descriptive comparison between the 2 alpha defensin tests and 4 other individual lab tests used in the MISI criteria to diagnose PJI (such as synovial fluid white blood cell count and erythrocyte sedimentation rate), the authors concluded that “alpha defensin tests led to the highest raw number of correct diagnoses (accuracy).”

The 2018 International Consensus Meeting on Orthopaedic Infections included alpha defensin as a minor criterion. That decision, along with these findings and the FDA approval of the lateral-flow test, should lead to increased adoption of the rapid test—and to more data being published on its clinical utility.

What’s New in Adult Reconstructive Knee Surgery 2021

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 such OrthoBuzz specialty-update summaries.

This month, author Michael J. Taunton, MD summarizes the 5 most compelling findings from the 130 studies highlighted in the January 20, 2021 “What’s New in Adult Reconstructive Knee Surgery.”

Waiting for a Knee Replacement
–Patient wait times for joint arthroplasty, exacerbated in many places by the COVID-19 pandemic, continue to increase. As measured by the EQ-5D, the health among 12% of 2,168 patients awaiting total knee arthroplasty (TKA) in a recent cross-sectional analysis was rated as “worse than death.”1 Joint-specific function and various comorbidities were associated with these findings.

UKA vs TKA
–The multicenter randomized TOPKAT trial2 compared unicompartmental knee arthroplasty (UKA) with TKA for treating medial compartment osteoarthritis. At the 5-year follow-up, there was no between-group difference in Oxford knee scores, but UKA was more cost-effective and provided an additional 0.24 quality-adjusted life year.

Perioperative Patient Optimization
–An observational study analyzing >1,000 total joint arthroplasties3 found that implementing a “perioperative orthopaedic surgical home”—a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities—resulted in a 1.6% 30-day readmission rate (versus 5.3% among patients not involved in the initiative).

Pain Management and Opioids
–A randomized controlled trial of >300 patients undergoing primary total knee or hip arthroplasty4 demonstrated that reducing the number of 5-mg oxycodone pills prescribed at discharge from 90 to 30 resulted in the following findings 30 days postoperatively:

  • Similar between-group pain scores
  • No between-group differences in patient-reported outcomes
  • Significant reductions in unused opioid pills and in pain pills taken in the 30-pill group

Periprosthetic Joint Infection
–Patients undergoing primary TKA who had a history of periprosthetic joint infection (PJI) in another joint had a significantly higher risk of PJI after the primary TKA, compared with the risk among a matched cohort with no history of PJI.5

References

  1. Scott CEH, MacDonald DJ, Howie CR. ‘Worse than death’ and waiting for a joint arthroplasty. Bone Joint J.2019 Aug;101-B(8):941-50.
  2. Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK; TOPKAT Study Group. The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. 2019 Aug 31;394(10200):746-56. Epub 2019 Jul 17.
  3. Kim KY, Anoushiravani AA, Chen KK, Li R, Bosco JA, Slover JD, Iorio R. Perioperative orthopedic surgical home: optimizing total joint arthroplasty candidates and preventing readmission. J Arthroplasty.2019 Jul;34(7S):S91-6. Epub 2019 Jan 18.
  4. Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, Gerlinger TL, Buvanendran A, Della Valle CJ. The James A. Rand Young Investigator’s Award: large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplasty.2019 Jul;34(7S):S4-10. Epub 2019 Feb 4.
  5. Chalmers BP, Weston JT, Osmon DR, Hanssen AD, Berry DJ, Abdel MP. Prior hip or knee prosthetic joint infection in another joint increases risk three-fold of prosthetic joint infection after primary total knee arthroplasty: a matched control study. Bone Joint J.2019 Jul;101-B(7_Supple_C):91-7.

JBJS Clinical Classroom: A Better Path to Orthopaedic Proficiency

In 2017, JBJS launched JBJS Clinical Classroom on NEJM Knowledge+, an adaptive learning platform that meets the unique learning needs and requirements of orthopedic surgeons worldwide. Clinical Classroom identifies gaps in individual users’ knowledge and assesses their self-confidence in 11 orthopaedic subspecialties. Curated by orthopaedic experts and powered by leading-edge learning technology, Clinical Classroom has quickly become a leading platform for orthopaedic surgeons who want to:

  • Improve their knowledge and critical thinking skills
  • Stay up-to-date with the latest and highest-quality orthopaedic findings
  • Earn AMA PRA Category 1 Credits™ (for US learners who successfully answer questions), and
  • Earn SAE credits for Maintenance of Certification (for US learners who successfully answer questions)

To meet changing user needs and implement technological advancements, JBJS has improved the overall user experience in Clinical Classroom. These significant changes were made possible by upgrading from the original Knowledge+ platform to the new Rhapsode platform by Area9.

Highlights of JBJS Clinical Classroom on Rhapsode include the following:

  • Enhanced look and feel: The clean, modern Dashboard and improved navigation allow you to interact with and move effectively throughout the product for optimal learning.
  • Updated adaptive algorithms that incorporate the most advanced adaptive tools for more efficient individualized learning
  • All-device access: Clinical Classroom is now user-friendly on all devices, with special enhancements for the mobile experience.
  • In-platform coaching delivers helpful tips tailored to your performance and confidence as you progress through subspecialties.
  • And so much more

To learn more about the enhanced JBJS Clinical Classroom on Rhapsode, and to stay up-to-date with ongoing developments, click here.

To explore Clinical Classroom pricing and subscription options, visit the JBJS Store today.

The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

A Closer Look at Impingement in Ceramic-on-Ceramic THA

Total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) bearings has become popular, especially in younger patients, largely because of the material’s durability. However, CoC bearings are susceptible to catastrophic failure through fracture. Although the definitive mechanistic pathway for ceramic fracture has not been elucidated, one of the proposed mechanisms is impingement between the ceramic acetabular liner and the metal neck of the femoral stem. In the January 20, 2021 issue of The Journal, Lee et al. take an illuminating radiographic dive into the patterns of impingement in CoC THA.

The authors analyzed 244 cases of CoC THAs that had ≥15 years of radiographic follow-up. They found impingement-related notches at 77 sites in 57 (23.4%) of the cases. The notches were seen either on the neck (28 cases) or on the shoulder (29 cases) of the stem. In 8 cases, notches were found in multiple locations.

All of the neck notches were found when either a medium-neck or long-neck head was used. Shoulder notches were found on the stem only when a short-neck head was used. Lee et al. observed that the use of medium-neck or long-neck heads prevents the ceramic liner from contacting the stem shoulder because the liner impinges on the neck first. The authors also noted that the mean cup inclination was significantly lower in the cases with notched stems compared to stems without notches (36.9° vs 39.8°), and that mean anteversion was higher in the cases with notches (19.9° vs 17.3°).

We have known that impingement can occur between the ceramic liner and metal stem in CoC THA, but this study suggests that it may happen in a significant proportion of patients, both along the neck and shoulder of the stem. Manufacturers should consider these findings when designing implants, and patients and surgeons considering CoC implants may want to avoid short-neck heads, if possible. Also, because impingement-related stem notching appears to occur more frequently with lower cup inclination and higher anteversion, surgical technique remains vitally important in these cases, independent of implant design and selection.

Finally, we should note that the patients in this study were young (mean age of 43 years) and Asian. Asian culture and lifestyle include frequent squatting and sitting cross-legged, which Lee et al. say “induces more impingement between the stem and liner.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Halt Bisphosphonates in Patients with an Atypical Femoral Fracture

Osteoporosis is the major contributor to the increasing incidence of fragility fractures associated with low-energy falls. The other contributor is the populous baby-boomer generation that is entering its final decades of life. Our orthopaedic community has made some progress in “owning the bone” to prevent fragility fractures. For example, we have gotten better at identifying a first fragility fracture as a major risk for a subsequent fracture; we more frequently initiate medical treatment for osteoporosis, and we are more inclined to refer patients with a first fragility fracture to a fracture liaison service, if one exists (see related OrthoBuzz posts).

However, orthopaedic physicians treating patients with fragility fractures need to remember that osteoporosis-treatment complications are also within our scope of responsibility. In the January 20, 2021 issue of The Journal, Lee et al. retrospectively analyzed 53 patients (all women, with an average age of 72 years) who had a complete atypical femoral fracture (AFF), a phenomenon primarily related to bisphosphonate treatment for osteoporosis. More than 37% of these patients were given bisphosphonates after their first AFF, and among those 53 patients who went on to show radiographic progression toward a second AFF in the contralateral femur, 61% used bisphosphonates after surgery for the first AFF.

The most shocking aspect of the findings by Lee et al. is the unacceptably high percentage of patients who remained on bisphosphonate therapy after the initial AFF. I wholeheartedly agree with Anna Miller, MD, who writes in her Commentary on this study that “an atypical stress fracture while on bisphosphonates should be considered a failure of bisphosphonate treatment, and that therapy should be stopped immediately.” If there is ongoing osteoporosis in such cases, the orthopaedic surgeon should consider prescribing an anabolic drug such as teraparatide or abaloparatide–and should communicate with the patient’s endocrinologist or other physician who might still be prescribing bisphosphonates.

In my opinion, we have to improve more quickly on both of these clinical issues–secondary fragility fracture prevention and treatment of bisphosphonate-therapy complications–because the population dynamics in the US and worldwide are evolving rapidly.

Click here to view a 2-minute video summary of this study’s design and findings.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Pediatric Limb-Lengthening: A Cautionary Tale

JBJS Editor-in-Chief Dr. Marc Swiontkowski brought to OrthoBuzz’s attention a recent “Family Partnerships” essay published in Pediatrics. The 4 “speakers” in the essay chronicle the suffering and pain of Lindsay Ellingworth, who was born with a congenital lower-limb deficiency. Lindsay’s young parents opted for limb lengthening over amputation plus a prosthesis after several orthopaedic consultations and an agonizing, confusing decision-making process.

Orthopaedic surgeon Dr. David Hootnick entered the picture about 10 years ago, when he first saw Lindsay, who was by then a young nursing student with ongoing problems associated with the index procedure—including scoliosis and chronic neck and back pain. The extent of the original deformity (30% femur shortening at birth) made Lindsay a “nonideal candidate for lengthening,” says Dr. Hootnick, but he adds that “Lindsay had a normal-appearing foot, making it all the more understandable that her parents balked at removing an apparently healthy part of their beloved child.”

Lindsay describes her limb-lengthening and years of treatments for complications as “a living nightmare.” Now an adult, she has concluded that “the doctors put a pretty bow on limb lengthening.” Pediatrician and bioethicist Dr. Amy Caruso Brown acknowledges in the essay the untenable bind Lindsay’s parents found themselves in when having to make a decision before their child was old enough to express preferences. “It is difficult to accept that a procedure that sounds as drastic and anachronistic as amputation might have fewer complications than the seemingly more sophisticated alternative,” Dr. Brown said.

According to Lindsay’s mother Rene Mauchin, “Although she has endured so much, Lindsay still laughs and celebrates life.” When asked for a takeaway that might help other families in similar situations, Ms. Mauchin said, “You have a right to know everything the doctors know…Don’t hesitate to see several doctors, and ask for evidence to back up their recommendations.”

When Does I&D Beat 2-Stage Exchange in Second rTKA?

It’s hard to contemplate “conservative treatment” in the case of a revised total knee arthroplasty (rTKA) with extensive instrumentation that needs a reoperation due to periprosthetic joint infection (PJI), because all the treatment options in that scenario are pretty complex. In the January 6, 2021 issue of JBJS, Barry et al. report on a retrospective review of 87 revisions of extensively instrumented rTKAs that found that irrigation and debridement (I&D) with chronic antibiotic suppression was as effective as 2-stage exchange in preventing another reoperation for infection—and more effective in terms of maintaining knee function.

The average follow-up of the cases studied was 3.2 years, and the authors carefully defined “extensive instrumentation.” Among the 56 patients who were managed with I&D and suppression and the 31 who were managed with the initiation of 2-stage exchange (average age in both groups approximately 67 years), no significant differences were found in the rates of reoperation for infection or mortality. However, 9 of the 31 patients (29%) in the 2-stage group never underwent the second-stage reimplantation. Among those 9, 3 died prior to reimplantation and 2 underwent amputation due to failure of infection control.

Moreover, at the time of the latest follow-up, a significantly higher percentage of patients in the I&D group were ambulatory (76.8% vs 54.8% in the 2-stage group) and were able to functionally bend their knee (85.7% vs 45.2% in the 2-stage group). The authors surmise that these 2 findings are related to the soft-tissue damage and bone loss that typically occur during stage-1 removal of rTKA components.

Barry et al. conclude that in similar situations “deviating from the so-called gold standard of 2-stage exchange and accepting the modest results of I&D may be in the best interest of the patient,” as long as there are no loose implants in the existing construct. But the “sobering” mortality rates in the study (39.3% in the I&D group and 38.7% in the 2-stage group) remind us that this clinical scenario is extremely challenging for patients and surgeons, no matter which option is selected.

Click here to view an “Author Insights” video about this study with co-author Jeffrey Barry, MD.

Same-Patient Trial Design Measures Incremental Improvements in TKA Outcomes

The clinical and functional outcomes after total knee arthroplasty (TKA) are generally very favorable. The 15% to 20% of subpar patient-reported outcomes are usually related to persistent pain. Orthopaedic researchers have exhaustively investigated patient factors and technical considerations to address dissatisfaction in this minority population of TKA patients.

Meanwhile, the orthopaedic community has focused on prosthetic design in its attempts to incrementally improve outcomes for the 80% to 85% of generally satisfied TKA patients. Clearly documenting those incremental improvements often requires elegant study design. That’s what we see in the January 6, 2021 issue of The Journal, where Kim et al. report findings from a randomized trial in which 2 different knee-implant designs were compared in the same patients after primary simultaneous bilateral TKA.

Each of the 50 patients (49 of them women) received a posterior-stabilized design in 1 knee and an ultracongruent prosthesis in the other. Kim et al. selected the Forgotten Joint Score (FJS) as the primary outcome. The FJS is a 12-item questionnaire that assesses patient awareness of the artificial joint during daily activities. At 2 years, the researchers found no between-knee differences in FJS. The ultracongruent knees showed more anteroposterior laxity and less femoral rollback than the posterior-stabilized knees, but there were, again, no between-group differences in following measures:

  • Range of motion
  • Knee Society and WOMAC scores
  • Side Preference and patient satisfaction

The ultracongruent advancement in prosthetic design does not appear to offer clinically important advantages over the posterior-stabilized design. But if additional TKA patients can be recruited into studies using clever and effective experimental designs like this one, the future is bright for more robust assessments of the incremental impact of prosthetic design on functional and clinical outcomes.

Click here to view an Infographic summarizing this study.

Marc Swiontkowski, MD
JBJS Editor-in-Chief