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Outpatient Knee Replacement Complications: How Important Are They?

Outpatient TKA for OBuzzIn the December 6, 2017 issue of The Journal, Arshi et al. report on a detailed analysis of a large administrative database, looking specifically at one-year complications associated with outpatient versus standard inpatient knee replacement. This type of analysis is crucial because of the rapidly growing interest in outpatient joint replacement among patients, payers, and the orthopaedic community.

The data convince me that these outpatient procedures should proceed, but with a little more caution. Although the absolute complication rates in both surgical settings were very low, after adjusting for age, sex, and comorbidities, the authors found a higher relative risk of several surgical and medical complications among outpatients—including component failure, infection, knee stiffness requiring manipulation under anesthesia, and deep vein thrombosis.

One important element that is lacking in this analysis is adjustment for surgeon/hospital volume. We know from important work by Katz and others that patients managed at centers and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events.

These results from Arshi et al. are definitely not a call to stop the expansion of outpatient joint replacement protocols. Instead, I think this study should prompt every joint-replacement center to analyze its risk-adjusted inpatient and outpatient outcomes—and to ensure, as these authors emphasize, that outpatients receive the same level of attention to rehabilitation, antibiotic administration, and thromboprophylaxis as inpatients.

Enhancing outpatient knee-replacement protocols will serve local communities well, and the nationwide orthopaedic community will receive further confirmation that outpatient joint replacement is a move in the right direction.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Pulsatile Lavage Harms Muscle in Rat Model of Blast Injury

Rat Limb for OBuzzBasic science investigations into clinically relevant orthopaedic conditions are very common—and often very fruitful. What’s not very common is seeing results from large, multicenter randomized trials published in the same time frame as high-quality in vivo basic-science research on the same clinical topic.

But the uncommon has occurred. In the November 1, 2017 issue of The Journal, Chiaramonti et al. present research on the effects of 20-psi pulsatile lavage versus 1-psi bulb-syringe irrigation on soft tissue in a rat model of blast injuries. With support from the US Department of Defense, Chiaramonti et al. developed an elegant animal study that found radiological and histological evidence that lavage under pressure—previously thought to be critical to removing contamination in high-energy open fractures—results in muscle necrosis and wound complications.

Although none of the rats developed heterotopic ossification during the 6-month study period, the authors plausibly suggest that the muscle injury and dystrophic calcification they revealed “may potentiate the formation of heterotopic ossification by creating a favorable local environment.” Heterotopic ossification is an unfortunately common sequela in patients who suffer blast-related limb amputations.

The aforementioned rare alignment between basic-research findings and clinical findings in people relates to a large multicenter randomized clinical trial recently published in The New England Journal of Medicine. That study found that one-year reoperation rates among nearly 2,500 patients treated surgically for open-fracture wounds were similar whether high, low, or very low irrigation pressures were used. This is a case where the clinical advice from basic-study authors Chiaramonti et al. to keep “delivery device irrigation pressure below the 15 to 20-psi range” when managing open fractures is based on very solid ground.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Long-term Results Show No Advantage to “Minimalist” THA

Minimal Incision THA for OBuzzThe debate regarding minimally invasive/minimal incision total hip arthroplasty (THA) has been simmering for a decade and a half. When assessing the impact of adult reconstruction procedures, patients and treating physicians alike are most interested in longer-term results. Improved return of function in the first 3 to 6 weeks is of some value to all patients—and perhaps of great value to younger patients—and that has been one of the purported advantages of the “minimalist” approach. But it is the long-term results that really matter.

In the October 18, 2017 issue of The Journal, Stevenson et al. provide 10-year results from a 2005 randomized trial of small-incision posterior hip arthroplasty, and they confirm it adds no clinical, radiographic, or implant-survivorship benefit when compared with a standard posterior approach. An extra caveat here is that these procedures, originally done in 2003-2004, were undertaken by a highly experienced surgeon who had performed >300 minimal-incision THAs. In the hands of surgeons with less experience, smaller incisions may result in suboptimal component positioning and other complications, a point emphasized by Stevenson et al. and by Daniel Berry in his JBJS editorial accompanying the original study.

This long-term data is of great value to patients and surgeons alike. It is my hope that such high-quality evidence will temper the claims used in marketing materials that hype minimally invasive approaches, to which hip surgeons are routinely subjected.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Aggressive Treatment Improves QOL in Many Cases of Spinal Metastases

swiontkowski marc colorA significant portion of metastatic disease comes with no clear identification of a primary tumor; this is unfortunately the case with many spinal metastases. In the October 4, 2017 issue of The Journal, Ma et al. evaluate the survival and patient-reported quality-of-life (QOL) outcomes for patients with spinal metastases from cancer of unknown primary origin.

Their prospective longitudinal study confirms that a more aggressive strategy that combines surgery and radiation therapy results in better QOL (as measured with the four-domain FACT-G instrument) than radiation alone. There was no significant difference in survival time between the two groups. In a subgroup analysis of patients receiving surgery, those who underwent circumferential decompression had significantly better functional and physical well-being and higher total QOL scores than those who underwent decompressive laminectomy.

These findings emphasize the critical role of shared decision making in such difficult situations. A dire diagnosis with poor statistical chances of long-term survival does not mean that patients should not be informed of treatment options and have the opportunity to opt for an aggressive surgical approach, especially if that decision is likely to result in improved QOL. Let us endeavor to compassionately provide patients with the facts, as we understand them, and let them select from among the medical and surgical options that are at their disposal. More often than not, in this sad scenario, it seems aggressive is better in terms of quality of life.

After Achilles Repair, Musculotendinous Strength Remains a Big Challenge

Calf MRI for OBuzzAmid ongoing uncertainty regarding the optimum management of Achilles tendon ruptures, recent controlled trials seem to have moved the pendulum back toward nonsurgical treatment. Still, there are many people walking around on surgically repaired Achilles tendons, and in the September 20, 2017 issue of The Journal, Heikkinen et al. report on the 13+-year outcomes of operative repair followed by early functional postoperative management in 52 patients.

All orthopaedic surgeons who have treated patients with this tendon injury have noted the postoperative calf atrophy. Using carefully analyzed MRI studies, these authors found that the mean volumes of the soleus, medial gastrocnemius, and lateral gastrocnemius muscles were 13%, 13%, and 11% lower, respectively, in the affected legs than in the uninjured legs. The mean 6% elongation of the repaired tendon that Heikkinen et al. also found at this long-term follow-up makes sense, because we are repairing tendinous tissue whose inherent collagen bundle structure has been “overstretched” prior to total failure. It also makes sense that surgeons are often hesitant to shorten the ends of the tendon aggressively for fear of placing too great a tensile strain on the suture repair.

What is most impressive to me is the degree of calf-muscle atrophy revealed in these results. Whether the findings from future trials tilt us further toward nonoperative or back toward operative care, we need to solve the muscle atrophy issue. The solution will most likely come from even more aggressive rehabilitation. To date, many of us have erred on the side of not pushing these patients too far during rehab, out of concern for failure of repair or reinjury.

With solid surgical and nonsurgical treatments for fractures, we have solved many issues to achieve optimum bone healing with good anatomic and strength outcomes. However, we have not really begun to make gains on limiting muscle, ligament, and tendon atrophy in lower extremity injuries. This should be high on the agenda for the trauma research community during the next 2 to 3 decades.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

D-Dimer Levels May Help with PJI Diagnoses

D-dimer for OBuzzThe percentage of periprosthetic joint infections (PJIs) among patients requiring revision arthroplasty of the hip and knee is increasing. PJIs have important clinical implications both for revision surgical procedures as well as pre- and postoperative management. Any extra help we can get making a PJI diagnosis outside of the obvious (where the patient presents with a draining wound) would be most welcome.

In the September 6, 2017 issue of The Journal, Shahi et al. present compelling data from a prospective study suggesting that serum D-dimer levels may help diagnose PJI—and thereby help determine the optimal timing of component reimplantation. The authors determined that 850 ng/mL was the optimal threshold value for D-dimer in diagnosing PJI. Moreover, with sensitivity of 89% and specificity of 93%, this test outperformed the widely used ESR and CRP tests, which until now have proven to be the “best” tools we have at our disposal.

Ideally, after these results are confirmed in larger populations of patients undergoing revision arthroplasty, the serum D-dimer test—inexpensive and almost universally available—will be used in all high-volume joint replacement centers. The continued pursuit of diagnostic and treatment methodologies for patients with suspected PJI is definitely warranted, given the increasing number of patients requiring arthroplasty and combined lifetime knee- and hip-replacement revision rates hovering around 10% to 12%. The identification of D-Dimer elevation as a potentially more accurate diagnostic tool than our currently available tests is a welcome contribution.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Rotator Cuff Repair Integrity is Important

Supraspinatus Tear for OBuzzAmong the estimated 250,000 surgical rotator cuff repairs performed annually in the US, a growing percentage are being done on younger patients to prevent tear propagation and tissue degeneration. But how durable are the outcomes of those procedures?

In the August 16, 2017 issue of The Journal, Collin et al. report the 10-plus-year results of surgical repair of isolated supraspinatus tears. In this rather large cohort (288 patients with an average age of 57 years evaluated clinically, with 210 of those also evaluated with MRI), complications were not uncommon at 10.4%. On a more positive note, the average Constant score improved from about 52 before surgery to 78 at 10 years after surgery. The 10-year Constant scores correlated with MRI-determined repair integrity but were inversely associated with preoperative fatty infiltration of the supraspinatus.

These findings imply that careful patient selection based on both clinical factors and imaging studies is critically important in identifying patients with the best chance for good, long-term functional results. The presence of a cuff tear, particularly a large chronic one, is not always a surgical indication for repair. For example, Collin et al. found that the rate of retears was significantly higher in patients >65 years old than in those who were younger.

As is frequently the case in orthopaedics, we need additional prospective research with long-term functional and anatomic repair outcomes to better understand which patients are most likely to benefit from early repair of an isolated supraspinatus tear.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Patient Decision Aids Work in Orthopaedics

patient decision aid image for obuzz.jpgDemographic reality dictates that orthopaedic surgeons will be under ever-increasing pressure to serve aging patients. This explosion in the need for diagnostic and treatment services calls for engaged and informed patients to work with physicians in a shared decision-making process.

In the August 2, 2017 issue of The Journal, Sepucha et al. document the positive impact that patient decision aids—succinct presentations of treatment options and their attendant risks and benefits—have in shared decision making for hip, knee, and spinal complaints. In this prospective cohort study focused on routine orthopaedic care, the authors show that decision aids lead to higher knowledge scores among patients, greater patient involvement in shared decision making, lower surgical rates, and better patient-experience ratings.

The quality of available decision aids is generally excellent, and they are typically more evidence-based than information patients can locate on the Internet. In this time when orthopaedic surgeons are evaluating higher volumes of patients, these tools can inform patients before or after they interact with their orthopaedist. In addition to providing everyday-language explanations of clinical benefits and risks, these aids help individual patients align their health-care decisions with their personal values, needs, and lifestyles. I hope that these tools will find increasing use over the next 5 to 10 years in the orthopaedic practice environment.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Where Does the Blood Flow in the Femoral Head?

Femoral Head Vasculature.jpegOsseous vascular anatomy has always been clinically relevant to orthopaedists, but its importance is sometimes overlooked. In the July 19, 2017 issue of The Journal, Rego et al. provide a precise topographic map of arterial anatomy in and around the femoral head.

Ever since Trueta’s classic work published in the British volume of JBJS in 1953, we’ve known that the terminal branches of the medial femoral circumflex system (also known as the lateral epiphyseal artery complex) supply blood to the majority of the femoral head. This information has proved critical in supporting treatment decisions for the management of femoral head and neck fractures. In those cases, surgeons typically perform ORIF through an anterior approach because it is remote from this posterior vascular supply.

The details in the Rego et al. study will help today’s and tomorrow’s arthroscopists more safely manage acetabular labral tears associated with cam deformities. In those settings, when increasing the “offset” across the femoral neck to decrease impingement, surgeons should limit the depth of bone removal to avoid injury to this important vascular network. Thanks to this study, operating surgeons now have precise anatomic information (albeit derived from non-deformed cadaver hips) with which to limit the risks of increasing the femoral head offset.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Remove or Retain the PCL in TKA?

Posterior Stabilized Knee for OBuzz.jpegIn the world of total knee arthroplasty (TKA), the arguments about retaining the posterior cruciate ligament (PCL) versus stabilizing the knee with posterior-stabilized components have raged for more than 30 years. The number of cohort studies and controlled trials attempting to clarify the issue have been too high to count. In the July 5, 2017 issue of The Journal, Vertullo et al. use the power of the Australian national joint registry to add additional important clinical information to the debate.

More than 62,000 TKA cases formed the substrate of this analysis. In a study-design twist, the revision-related outcomes were analyzed on the basis of the preference surgeons had for the two different design options, not on the basis of which prostheses were actually used. Consequently, there was a likelihood that the cohort of patients treated by surgeons who had a preference for posterior-stabilized designs would include some PCL-retained cases, and vice-versa. The authors claim that this “instrumental variable analysis” has “the capacity to remove the confounding by indication or disease severity against posterior-stabilized total knee replacements.” However, as with any registry study, there were still many confounding variables that could have influenced the revision rate, not the least of which is surgeon skill in component alignment and ligament tensioning.

Nevertheless, with selection bias minimized, Vertullo et al. found a real difference in revision rates favoring retention of the PCL. That finding does make biomechanical sense to this non-arthroplasty surgeon, who would expect less stress on the tibial component-bone interface at the extremes of knee motion with the PCL-retaining procedure.

Biomechanics notwithstanding, I think this very large registry-based arthroplasty study will influence the debate going forward, but I doubt it will end the debate or that it will change the TKA practices of many surgeons worldwide. For a more definitive and potentially practice-changing resolution to this clinical conundrum, we’ll need a very large (2,000 to 3,000 patients in each arm) international trial where surgeons and patients accept randomization between these two choices.

Marc Swiontkowski, MD
JBJS Editor-in-Chief