Archive | July 2021

What’s New in Musculoskeletal Infection 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Thomas K. Fehring, MD summarizes the 5 most compelling findings from the >90 studies highlighted in the recently publishedWhat’s New in Musculoskeletal Infection.”

Albumin and Complication Risk

One recent study evaluated the effect of albumin levels on complications following primary and revision total joint arthroplasties (shoulder, elbow, wrist, hip, knee, ankle, or fingers). Patients with lower albumin levels preoperatively were at significantly increased risk for infection, pneumonia, sepsis, and other adverse outcomes compared with patients with normal albumin levels.

Antibiotic Prophylaxis and SSI Risk

–A retrospective cohort study using data from 436,724 total hip arthroplasty (THA) and 862,918 total knee arthroplasty (TKA) procedures examined antibiotic prophylaxis patterns and surgical site infection (SSI) risk1. Patients who received IV antibiotics other than cefazolin preoperatively had a higher risk of SSI.

Corticosteroid Injections and PJI

– A study using a large national database found that patients who underwent TKA and received a postoperative intra-articular corticosteroid injection (5,628 of 166,946 TKAs, 3.4%) had a significantly higher rate of periprosthetic joint infection (PJI) compared with a matched control cohort who did not receive an injection2.

Two-Stage Exchange

–A multicenter randomized controlled trial found that a 3-month course of microorganism-directed oral antibiotics significantly reduced the rate of failure from further infection after 2-stage revision of THA or TKA for chronic PJI3. Among 185 patients, treatment success was achieved for 87.5% of the patients who received 3 months of antibiotics vs 71.4% of those who did not.

Oral Antibiotics in Revision Arthroplasty

–Another multicenter randomized controlled trial evaluated the utility of adding rifampin to conventional antimicrobial therapy in cases of staphylococcal PJI treated with debridement and retention of the implant4. No significant advantage of adding rifampin to standard antibiotic therapy was found.

References

  1. Zastrow RK, Huang HH, Galatz LM, Saunders-Hao P, Poeran J, Moucha CS. Characteristics of antibiotic prophylaxis and risk of surgical site infections in primary total hip and knee arthroplasty. J Arthroplasty. 2020 Sep;35(9):2581-9. Epub 2020 Apr 18.
  2. Roecker Z, Quinlan ND, Browne JA, Werner BC. Risk of periprosthetic infection following intra-articular corticosteroid injections after total knee arthroplasty. J Arthroplasty. 2020 Apr;35(4):1090-4. Epub 2019 Nov 16.
  3. Yang J, Parvizi J, Hansen EN, Culvern CN, Segreti JC, Tan T, Hartman CW, Sporer SM, Della Valle CJ; Knee Society Research Group. 2020 Mark Coventry Award: microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years. Bone Joint J. 2020 Jun;102-B(6_Supple_A):3-9.
  4. Karlsen ØE, Borgen P, Bragnes B, Figved W, Grøgaard B, Rydinge J, Sandberg L, Snorrason F, Wangen H, Witsøe E, Westberg M. Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial. J Orthop Surg Res. 2020 Aug 28;15(1):365.

BMI Differentially Moderates Heritability of THA and TKA for Osteoarthritis

Genetic susceptibility to orthopaedic conditions is of interest to clinicians and patients alike. While the link between genetics and certain pediatric conditions is known, studies of sets of twins are providing new insights into adult issues, such as osteoarthritis, and the impact that genetics may have.

In the current issue of JBJS, Hailer et al. report on an investigation in Sweden in which they analyzed genetic susceptibility to hip and knee osteoarthritis necessitating total hip arthroplasty (THA) or total knee arthroplasty (TKA), and whether body mass index (BMI) moderates the heritability of these outcomes. They linked nearly 30,000 twin pairs with BMI information in the Swedish Twin Registry with the Swedish National Patient Register to identify twins who had undergone THA or TKA with a primary diagnosis of osteoarthritis. Structural equation modeling was then used to calculate the heritability of osteoarthritis treated with THA or TKA and how it related to BMI, age, and sex.

The authors note that, for radiographically defined knee osteoarthritis, previous twin studies have shown that the genetic susceptibility (“the proportion of the variation of a trait that can be attributed to the variation of genetic factors”) is between 0.4 to 0.8. In twin studies using total joint replacement as the outcome, heritability has been estimated to be 0.2 for TKA and 0.5 for THA.

Hailer et al. found that, on average in their cohort, approximately half of the susceptibility to undergo THA or TKA for osteoarthritis was explained by heritability, with similar estimates demonstrated for the 2 procedures: THA, 0.65 (95% CI, 0.59 to 0.70) and TKA, 0.57 (95% CI, 0.50 to 0.64). Of note, heritability decreased with higher BMI in both men and women for THA and in men for TKA. But in women, heritability for TKA increased with higher BMI (0.37 for a BMI of 20 kg/m2 and 0.87 for a BMI of 35 kg/m2).

Although the need for THA or TKA is not a perfect indicator of osteoarthritis (plenty of osteoarthritis does not become symptomatic enough to warrant total joint arthroplasty), this large study offers further data on the question of genetic susceptibility to the development of osteoarthritis. Understanding the influence of obesity (a modifiable risk factor) becomes increasingly important and warrants continued investigation in studies exploring heritability in relation to orthopaedic conditions. 

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

Ten-Year Results of the BIRMINGHAM HIP Resurfacing Implant System 

There have been 3 historic cycles of interest in surface replacement of the hip in the last 40 years. The second cycle occurred in the 1980s into the 1990s, when very high failure rates were reported. Biomaterial and design advancements fueled the most recent cycle of interest, which began 12 to 15 years ago. However, the enthusiasm that occurred at the advent of this most recent cycle ebbed as it became increasingly apparent that patient selection is critical and that the fairly difficult hip resurfacing procedure requires experience to reproducibly place the implants correctly. 

In the latest issue of JBJS,  Su et al. report the 10-year results of the post-market-approval study of the BIRMINGHAM HIP Resurfacing (BHR) implant system, a metal-on-metal system approved by the U.S. Food and Drug Administration in 2006. The study included a cohort of 280 hips (253 patients) undergoing primary BHR procedures across 5 sites. The mean patient age at the time of surgery was 51 years; 74% of the BHRs were implanted in male patients, and 95% of the hips had a diagnosis of osteoarthritis.  

Among the findings: 

  • 10-year survivorship free from all-cause component revision was 92.9%. Among male patients <65 years of age at the time of the procedure, the rate was 96%. 
  • Twenty hips underwent revision (at a mean of 5 years).  
  • Whole-blood cobalt and chromium levels were higher at 1 year after surgery compared with preop levels; they remained stable through 5 years, and then decreased somewhat at 10 years.  
  • Improvements in the EQ-5D visual analogue scale score and Harris hip score were noted at 1 year and were maintained through 10 years.  

These outcomes are encouraging, but as Su et al. point out, the cohort is not representative of typical total hip arthroplasty populations, who tend to be older and include a greater percentage of female patients. Moreover, the surgeons who performed the procedures were all experienced. Patient selection remains key, with younger male patients being the best candidates. Data such as these can help sharpen our focus as we refine arthroplasty concepts for further improvement in patient outcomes. 

For additional perspective on this study, see the commentary by Timothy S. Brown, MD 

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

A Creative Approach to COVID-Era Journal Clubs

All recipients of the JBJS Robert Bucholz Journal Club Grant are asked to complete an end-of-year survey that includes a question about how they used the grant money. This interesting reply comes from Kyle Morgenstern, MD, an orthopaedic resident at the University of Minnesota.

Resident engagement in journal clubs has been a challenge over the last couple of years. In our hard-working residency it is tough for residents to take time out of their evening every month for journal club. Formerly, we used the JBJS grant funds to purchase food and drinks for attendees. But with the virtual nature of journal club this past year, we saw our attendance start to slide and had to find other ways to recruit residents and boost morale.

So at the beginning of the COVID era, we utilized the grant money to purchase items awarded to attendees for their participation. I figured that if we couldn’t offer food and drink in person, we could at least do it virtually, and we awarded DoorDash gift cards.

Later, we transitioned to awarding a textbook to one presenter at each Journal Club. The winner of the textbook for best presentation was selected via an anonymous Zoom-poll vote of the faculty in attendance. We do Journal Club “Specialty Nights,” so, for example, we awarded Operative Techniques in Shoulder and Elbow Surgery during our shoulder-and-elbow night.

Those who received a textbook were quite thankful, especially those entering their trauma rotations or going into a particular subspecialty. I think this is something we will continue to budget for in the future, as we return to in-person meetings coming out of the pandemic.”

Applications for the 2021-2022 Robert Bucholz Journal Club grant are now available. Please click here.

Decrease in Inflation-Adjusted Medicare Reimbursement for Revision THA 

In a study now reported in JBJS, Acuña et al. analyzed Medicare reimbursements associated with revision total hip arthroplasty (THA) procedures. After adjusting for inflation, they found that the mean physician fee reimbursement for revision THA due to aseptic complications declined by a mean of 27% for femoral component revision, 27% for acetabular component revision, and 28% for both-component revision from 2002 to 2019. For 2-stage revision due to infection, they found that mean reimbursement fell by 19% and 24% for the explantation and reimplantation stages, respectively.  

The total decline in reimbursement for revision THA due to infection ($1,020.64 ± $233.72) was significantly greater than that for revision due to aseptic complications ($580.72 ± $107.22) (p < 0.00001). 

Reflecting on their investigation, the authors note: 

In light of persistent cost pressures and discussions surrounding the future of total hip arthroplasty reimbursement, our study explores temporal trends in the Centers for Medicare & Medicaid Services (CMS) physician fee schedule for revision THA procedures. Our findings, showing a significantly larger decline for septic revision THA reimbursements compared to their aseptic counterpart, may have important implications for ongoing discussions surrounding the CMS physician fee schedule.” 

They conclude in their study that, “continuation of this trend [of decreased reimbursement] could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level.” 

Click here for the full JBJS report. 

A recent OrthoBuzz post on reimbursement for revision TKA can be found here. 

 

What’s New in Orthopaedic Trauma 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Mai P. Nguyen, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the recently published “What’s New in Orthopaedic Trauma.”

Proximal Humeral Fracture 

–The DelPhi (Delta prosthesis-PHILOS plate) study, a multicenter, single-blinded, randomized controlled trial (RCT), evaluated the outcomes of reverse shoulder arthroplasty vs open reduction and internal fixation for displaced proximal humeral fractures in elderly patients. The results favored reverse shoulder arthroplasty (mean 2-year Constant-Murley score of 68.0 vs. 54.6 points for the 2 groups, respectively).

Hip Fracture 

–An RCT comparing hemiarthroplasty with or without cement in elderly patients with a displaced intracapsular fracture of the hip found better results for cemented hemiarthroplasty1. The number of mortalities was slightly higher in the uncemented group, although not significantly so (64 patients compared with 51; p 0.18). Although pain scores and reoperations were similar between the groups, better recovery of mobility was noted for the cemented group.

Proximal Femoral Fracture 

–Another recent RCT investigated the efficacy of a preoperative fascia iliaca compartment block (FICB) for patients with proximal femoral fractures (neck, intertrochanteric, or subtrochanteric regions)2. Lower morphine consumption (0.4 vs 19.4 mg; p = 0.05) and greater patient-reported satisfaction (31%; p = 0.01) were noted for the FICB cohort.

Ankle Fracture

–Among patients treated for unstable, rotational-type ankle fractures, a prospective RCT compared weight-bearing at 2 vs 6 weeks postoperatively3. Early weight-bearing at 2 weeks was associated with higher EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) scores at the 6-week follow-up. No difference, however, was seen at later follow-up time points.

Recovery After Trauma 

–The impact of trauma recovery services (TRS), which provide education and psychosocial support to patients with trauma and their families, was assessed in a recent study4. A total of 294 patients with operatively treated extremity fractures were prospectively surveyed. Injury, social, and demographic characteristics were studied for a possible association with patient-satisfaction scores. Use of TRS was the greatest predictor of better overall care ratings.

References

  1. Parker MJ, Cawley S. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip: a randomized trial of 400 patients. Bone Joint J. 2020 Jan;102-B(1):11-6.
  2. Thompson J, Long M, Rogers E, Pesso R, Galos D, Dengenis RC, Ruotolo C. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2020 Jan;34(1):49-54.
  3. Schubert J, Lambers KTA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-65. Epub 2020 Mar 6.
  4. Simske NM, Benedick A, Rascoe AS, Hendrickson SB, Vallier HA. Patient satisfaction is improved with exposure to Trauma Recovery Services. J Am Acad Orthop Surg. 2020 Jul 15;28(14):597-605.

Changes in 24-Hour Physical Activity Patterns and Walking Gait Biomechanics After Primary Total Hip Arthroplasty

Together with improvements in self-reported pain and perceived physical function, patients had significantly improved gait function postoperatively.

Read the full article here.

Minimally Invasive Hallux Valgus Correction: Promising Outcomes of Third-Generation Technique  

The field of orthopaedics continually seeks to improve our ability to help patients return to optimal function as quickly and efficiently as possible. New surgical techniques aimed at better outcomes, faster recovery, and smaller (and hopefully less painful) scars are regularly being developed and evaluated. The concept of minimally invasive surgery (MIS) has been around for some time, with newer techniques being utilized in multiple subspecialties. Foot and ankle surgery is no exception, with procedures including MIS for hallux valgus deformity correction. While early generations of such procedures were fraught with complications, newer, third-generation MIS (involving screw fixation of a distal metatarsal osteotomy site) has shown promising early results, with a documented learning curve of 20 to 50 cases.

In the July 7, 2021 issue of JBJSLewis et al. present their results from a consecutive series of third-generation minimally invasive chevron and Akin osteotomies (MICA) in the treatment of hallux valgus. Patient-reported outcome measures (PROMs) collected preoperatively and at a minimum of 2 years postoperatively as well as radiographic outcomes and complications were evaluated.

From the initial series of 333 feet (230 patients), PROMs data were available for 292 feet, or 87.7% (200 patients). PROMs utilized included the Manchester-Oxford Foot Questionnaire (MOXFQ), a tool specifically validated for patients undergoing hallux valgus surgery; the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index and EuroQoL visual analogue scale (EQ-VAS), validated quality-of-life measures; and a VAS for pain.

The authors found a significant improvement (greater than the minimal clinically important difference) in each domain of the MOXFQ. They also noted a significant improvement in the VAS-pain score and the EQ-5D-5L Index.

There was an overall 21.3% complication rate, with only 7.8% of the cases requiring a return to the operating room, most frequently for screw removal (6.3%). The operating surgeon was outside the reported learning curve, having previously performed approximately 100 MICA procedures, but there were still complications that can help guide the physician-patient discussion regarding the use of the MICA.

Although radiographic follow-up did not routinely go beyond 6 weeks, the authors found significant improvement in radiographic measures. With >25% of the preoperative deformities being classified as “severe,” the findings suggest the potential utility of the procedure for patients with a range of deformity severity.

This series—which the authors note is the largest of the third-generation MICA technique— opens the door for possible head-to-head comparison with traditional hallux valgus surgery via a randomized trial to further define the role of MICA in the treatment of patients with hallux valgus.

A Video Summary of this article can be found here.

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

The Cost-Effectiveness of Fragility-Fracture Screening and Prevention

After nearly 2 decades, the orthopaedic community has made a good start on assuming our responsibility in the diagnosis of osteoporosis after a patient’s initial low-energy fracture. We are seeing a positive impact from programs such as the American Orthopaedic Association’s “Own the Bone” initiative as well as from the expanded creation of multidisciplinary fracture liaison services, through which patients who sustain a fragility fracture can receive appropriate follow-up to reduce the risk of subsequent injury.   

There is still work to do to convince the wider orthopaedic surgeon community that leadership on this issue falls in our area. Primary care, rheumatology, and physiatrist practices are overwhelmed with patients with other clinical issues that require their resources. At the same time, it is easier to identify patients who may need treatment for low bone density during their initial encounter in the orthopaedist’s office or during a hospital admission. There is good evidence to suggest that patients are much more receptive to following through with laboratory testing and bone-density screening when they are being treated for a serious metaphyseal fracture.  

In the July 7 issue of JBJS, Saunders et al. examine the cost-effectiveness of a fracture liaison service, presenting their findings of a cost analysis of the Fracture Screening and Prevention Program (FSPP) of Ontario, Canada. Established in 2007, the FSPP was gradually implemented in 37 outpatient fracture clinics in the province; in 2011, the initial education-communication model was replaced by a more intensive strategy, with fracture risk assessment and referrals to specialists being added.  

The researchers’ goal was to determine the cost-effectiveness of the current FSPP compared with usual care (no program). They developed a Markov model and simulated a cohort of patients with a fragility fracture starting at 71 years of age, with model parameters obtained from the published literature and the FSPP.  

The authors concluded that, from the public health-payer perspective, the program is indeed less costly (by $274) and more effective (by 0.018 quality-adjusted life-year) over the lifetime of the patient. Read the full report here.  

We have seen that fracture liaison services can be beneficial to the individual patient. Data such as those from Saunders et al. can help to quantify—for payers and health systems—the value of those services, as our specialty takes on the responsibility of ensuring that patients receive appropriate screening for fracture risk and prevention.

Marc Swiontkowski, MD 
JBJS Editor-in-Chief