Archive | August 2021

JBJS at the Annual Meeting

JBJS will have a booth at the upcoming Annual Meeting in San Diego. The conference begins today, August 31, and runs until September 4. Stop by the JBJS booth to take part in special giveaways, take advantage of new sale offers, and chat with our editors.

JBJS will also be hosting Coffee & Conversation with Editor-in-Chief Dr. Marc Swiontkowski on Wednesday morning.

 

A Real-World Economic Evaluation: TSA vs Hemiarthroplasty

In a new study reported in JBJS, Lapner et al. conducted a cost-utility analysis of total shoulder arthroplasty (TSA) versus hemiarthroplasty from the perspective of Canada’s publicly funded health-care system. They used a Markov model to simulate the costs and quality-adjusted life-years (QALYs) for patients undergoing either TSA or hemiarthroplasty over a lifetime horizon to account for costs and medically important events over the patient lifetime. Subgroup analyses by age groups (≤50 or >50 years) were also performed.

Discussing their findings, the authors note:

Our analysis demonstrated that TSA was more cost-effective compared with hemiarthroplasty. This study involved a large cohort of patients (5,777) who underwent TSA or hemiarthroplasty. The data demonstrate that, despite the additional initial cost of TSA implants, health-care utilization postoperatively was greater for hemiarthroplasty compared with TSA and utility scores for hemiarthroplasty were inferior. Our findings can help inform both clinical decision-making as well as health-care policy with respect to these treatments.”

Click here for the full JBJS report.

JBJS Author Insights: Dr. Jeremy Smith

Co-author Jeremy Smith, MD discusses the new JBJS study “Correlation Between Patient-Reported Outcome Measures and Health Insurance Provider Types in Patients with Hip Osteoarthritis.” Watch the video below.

Read the full report here.

What’s New in Limb Lengthening and Deformity Correction 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 subspecialty areas. Click here for a collection of all such OrthoBuzz Guest Editorial summaries. 

This month, co-author Andrew G. Georgiadis, MD selected the 5 most clinically compelling findings from among the >60 studies highlighted in the most recent What’s New in Limb Lengthening and Deformity Correction.” 

Limb Lengthening 

–Investigators in one recent study used an internal extramedullary technique to achieve femoral lengthening in 11 skeletally immature patients1. Complication rates were similar to those seen with other femoral-lengthening techniques, which suggests that newer technology could be developed for all-internal lengthening in this younger age group. 

Congenital Limb Deficiencies 

–In an essay, a young woman who was born with congenital short limb and her mother offer their perspectives on a childhood “interrupted” by multiple limb-lengthening procedures2 

Bone Dysplasias and Tumors 

–In a retrospective study of 10 patients with congenital tibial dysplasia, researchers evaluated isolated distal tibial growth modulation as the primary surgical treatment3. Mean follow-up was 5.1 years. No patient sustained a tibial fracture or developed a tibial pseudarthrosis after guided growth was initiated. 

Blount Disease 

–A retrospective multicenter study assessed the use of guided growth in the correction of Blount disease in 45 patients (55 limbs)4. The authors found that 64% to 88% of cases could be corrected at a mean of 24 months. The mean correction rate was 1° per month. 

Trauma 

–In a study involving a caprine model of tibial osteotomyresearchers evaluated animal groups treated with static fixation, dynamic fixation, and reverse dynamization. They found that reverse dynamization was superior for speed and strength of bone-healing5. 

References 

  1. Dahl MT, Morrison SG, Laine JC, Novotny SA, Georgiadis AG. Extramedullary motorized lengthening of the femur in young children. J Pediatr Orthop. 2020 Nov/Dec;40(10):e978-83. 
  2. Hootnick D, Ellingsworth L, Mauchin R, Brown AC. “It occupied her entire childhood”: looking back on limb-lengthening. Pediatrics. 2021 Feb;147(2):e20201055. Epub 2021 Jan 5. 
  3. Laine JC, Novotny SA, Weber EW, Georgiadis AG, Dahl MT. Distal tibial guided growth for anterolateral bowing of the tibia: fracture may be prevented. J Bone Joint Surg Am. 2020 Dec 2;102(23):2077-86. 
  4. Danino B, Rödl R, Herzenberg JE, Shabtai L, Grill F, Narayanan U, Gigi R, Segev E, Wientroub S. The efficacy of guided growth as an initial strategy for Blount disease treatment. J Child Orthop. 2020 Aug 1;14(4):312-7. 
  5. Glatt V, Samchukov M, Cherkashin A, Iobst C. Reverse dynamization accelerates bone-healing in a large-animal osteotomy model. J Bone Joint Surg Am. 2021 Feb 3;103(3):257-63. 

ACL Reconstructions: Who Needs Them? 

Anterior cruciate ligament (ACL) injuries once were career-ending for athletes. With the advent of ACL reconstruction, elite athletes have been able to continue to compete at the highest level. But a question remains regarding recreational athletes and their need for reconstruction following ACL injury. Literature has shown that there are “copers” who are able to deal with an “ACL-deficient” knee, but are these individuals destined to participate in only low-impact activities without cutting and twisting? 

In the latest issue of JBJS, Pedersen et al. shed new light on this important topic, reporting the 5-year outcomes of the Delaware-Oslo ACL Cohort Study, a longitudinal study of patients who had been active in cutting, jumping, and pivoting sports before sustaining a unilateral ACL injury. The original cohort underwent 5 weeks of rehabilitation and then participated in a shared decision-making process to determine their treatment path. Inclusion criteria included involvement in level-I sports (such as soccer, football, handball, or basketball) or level-II activities (such as tennis, skiing, softball, baseball, or gymnastics) at least 2 times per week prior to injury.  

Treatment status at 5 years was known for 262 of the original 276 patients: 167 (64%) underwent early ACL reconstruction, 30 (11%) underwent delayed ACL reconstruction after having tried the path of rehabilitation only, and 65 (25%) opted for progressive rehabilitation alone. The patients who chose progressive rehabilitation alone were significantly older, less likely to participate in level-I sports preinjury, and less likely to have injuries to the medial meniscus compared with patients in the 2 reconstruction groups.  

Interestingly, at 5 years, no significant differences were found between the 3 groups in terms of clinical, functional, or physical activity outcomes as assessed by several measures.   

There were narrow indications for inclusion in the study, including no substantial concomitant knee injuries, and patients needed to have full resolution of acute impairments before being enrolled. That being said, at follow-up, 95% to 100% of patients across groups were still active in some kind of sports. This gives hope to older guys like me that maybe we don’t need to fear an ACL injury ending our weekend careers of showing our kids “how it’s really done.” Maybe former athletes like myself would fall into that group of “copers” who can still be relatively active with an “ACL-deficient” knee? 

Click here for the related JBJS video summary of this article. 

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

Reconstruction for Chronic ACL Tears with or without Anterolateral Structure Augmentation in Patients at High Risk for Clinical Failure

Compared with isolated ACLR, combined ACLR and ALSA resulted in a reduction in persistent rotatory laxity and higher rates of return to preinjury and competitive levels of play at 2 years of follow-up in the population studied.

Read the full article here.

Rehabilitation Strategies: Fertile Ground for Prospective Randomized Trials

Approximately 18% of JBJS scientific studies published in 2020 were Level I or II investigations. The number of high-level studies has continued to grow slowly year over year. In terms of randomized controlled trial design, we have found that the facets of care that are often the focus of study are those that are most straightforward—the use of tourniquets, resurfacing the patella with total knee arthroplasty, intraoperative and postoperative drug therapies, as examples. One under-investigated area is rehabilitation, as far as both management strategies post-injury and more detailed, comprehensive post-surgical programs.

In the latest issue of JBJS, Martínez et al. evaluate the question of duration of sling use following proximal humeral fracture in patients managed nonoperatively. This is an important patient centric question that has largely been informed by “hand me down” prescriptions from residency teaching faculty. In a very well-designed Level II trial involving an adult cohort (mean age of 70; range, 42 to 94 years), they found no significant differences in pain and function between patients randomized to 1 week of immobilization versus 3 weeks of immobilization. In addition, no significant difference in the complication rate was found.

Pain was assessed using a visual analog scale at 1 week and 3 weeks after fracture and then at the 3, 6, 12, and 24-month follow-up. Functional outcome was evaluated using the Constant score, and functional disability was evaluated with the Simple Shoulder Test, a self-reported questionnaire; both of these measures were recorded at the 3, 6, 12, and 24-month evaluation. No differences in pain and function at any time point were observed.

Many readers of JBJS have had the experience of patients abandoning the sling as soon as they are comfortable, regardless of what our original instructions were, so the findings of this study are relatable. The authors concluded that, “These fractures can be successfully managed with a short immobilization period of 1 week in order not to compromise patients’ independence for an extended period.”

It strikes me that there are numerous rehabilitation prescriptions that are ripe for evaluation using a randomized design. (Wear an orthosis when sleeping? Keep it on at all times or only when walking? Etc.) Let’s get after these questions in the manner of Martinez et al. as we seek to give our patients solid evidence to back our instructions.

A downloadable JBJS infographic regarding this study can be found here.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?

Our study demonstrated no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture-healing. However, continued use of these medications for a period of >3 weeks may be associated with higher rates of nonunion or delayed union.

Read the full article here.

JBJS OA Participates in Research4Life Program

JBJS Open Access (JBJS OA) is an international, peer-reviewed, open-access journal from the publishers of The Journal of Bone & Joint Surgery. The mission of this continuously published online journal is to provide a steady flow of comprehensive, objective, and evidence-based basic-science and clinical studies that have the potential to impact orthopaedic care worldwide.

JBJS OA welcomes original articles that contribute to orthopaedic knowledge from all sources in all countries, with the goal of improving the quality of care of orthopaedic patients. To this end, JBJS OA is pleased to participate in the Research4Life waiver program and offers full or partial equitable waivers for accepted articles from low-income and middle-income economies. Eligibility is based on the Research4Life eligibility criteria, which can be found here. Countries listed in Group A are eligible for the full waiver and countries listed in Group B are eligible for the partial (50%) waiver. The waiver is automatically applied based on the Corresponding Author’s country information provided during submission.

For more information about JBJS OA submission guidelines and author instructions, please visit the JBJS OA Author Resource Center.

JBJS Essential Surgical Techniques Awards

JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) video article, and the other for the best Key Procedures (KP) video article published during each calendar year.  

We are pleased to spotlight the 2020 Award Winners: 

Editor’s Choice Subspecialty Procedures Award 

Minimally Invasive Sacroiliac Joint Fusion: A Lateral Approach Using Triangular Titanium Implants and Navigation
by David W. Polly Jr., MD, and Kenneth J. Holton, MD 

Editor’s Choice Key Procedures Award 

Computerized Navigation: A Useful Tool in Total Knee Replacement
by Oystein Gothesen, MD, PhD; Oystein Skaden, MD; Gro S. Dyrhovden, MD; Gunnar Petursson, MD, PhD; and Ove N. Furnes, MD, PhD 

Both articles are freely available online. 

Submissions for the 2021 EST Awards are currently being accepted.