Long-term Results Show No Advantage to “Minimalist” THA
The 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
A 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
Amid 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
The 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
Among 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
Demographic 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?
Osseous 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?
In 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
Does Hip Arthroscopy Really Help?
Over the past 15 to 20 years, the use of arthroscopic procedures for hip pathologies has rapidly increased. Leaders in sports medicine have standardized many arthroscopic techniques, including methods of joint distraction, portal location, approaches to labral repair or debridement, and management of cartilage lesions.
Many in the orthopaedic community have wondered whether this expansive use of hip arthroscopy is justified by significant improvement in patient function or is simply a first (and perhaps overused) step toward inevitable hip arthroplasty. To help answer that question, in the June 21, 2017 issue of The Journal, Menge et al. document the 10-year outcomes of arthroscopic labral repair or debridement in 145 patients who originally presented with femoroacetabular impingement (FAI).
Whether these patients were treated with debridement or repair, their functional outcomes and improvement in symptoms were excellent over the 10-year time frame, and the median satisfaction score (10) indicates that these patients were very satisfied overall. However, as seen in other similar studies in the peer-reviewed literature, the results in older patients with significant cartilage injury or radiographic joint space narrowing were inferior, and most of the patients with these characteristics ended up with a hip replacement.
The Menge et al. study helps confirm that arthroscopic repair or debridement in well-selected FAI patients yields excellent longer-term outcomes, and it provides concrete criteria for patient selection.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Good Outcomes with After-Hours Hip Fracture Surgery
In the June 7, 2017 issue of The Journal of Bone & Joint Surgery, Pincus et al. report on a careful analysis comparing outcomes from hip fracture surgery occurring “after hours” (defined by the authors as weekday evenings between 5 PM and 12 AM) with surgeries occurring during “normal hours” (weekdays from 7 AM to 5 PM). In the busy Ontario trauma center where this study was performed, it is common for patients with blunt trauma to take precedence over seniors who are relatively stable but in need of hip fracture care.
Pincus et al. found that adverse outcomes, in terms of surgical and medical complications, were similar whether the hip surgery occurred during normal hours or after hours. Interestingly, there was a higher rate of inpatient complications in the normal-hours group, and fewer patients in the after-hours group were discharged to a rehab after surgery than in the normal-hours group.
It has been my impression that highly skilled professional surgeons and their teams are going to put forward their best efforts for all patients—no matter what time of day or night they operate. Concentration, focus, and high standards can generally overcome fatigue. However, the Pincus et al. study should not be viewed as justification for hospital decision makers to forget their commitment to optimize management of all resources, including surgical teams. After-hours care should never become “routine,” and there should be continuous attention on developing alternative solutions, such as moving elective surgery to other facilities or true shift scheduling that provides all members of the team with occasional daytime hours off for rest and management of personal lives.
The authors note that in their Canadian jurisdiction, there are hospital and surgeon-reimbursement incentives that may work to promote after-hours surgery, but the long-term focus must always put patient outcomes first. And we must always remember that good patient outcomes rely on maintaining surgical teams who are experienced and not burnt out.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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