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JBJS Editor’s Choice—Nonunions of Foot/Ankle Fusions Matter

Ankle_Fusion_12_7_16.pngIn the December 7, 2016 issue of JBJS, Krause et al. analyze data from a 2013 industry-sponsored RCT to investigate correlations between nonunions of hindfoot/ankle fusions indicated by early postoperative computed tomography (CT) and subsequent functional outcomes. Whether nonunion was assessed by independent readings of those CT scans at 24 weeks or by surgeon composite assessments at 52 weeks, patients with failed healing had lower AOFAS, SF-12, and Foot Function Index scores than those who showed osseous union.

This study suggests that a CT should be obtained from patients who are at least 6 months out from a surgical fusion and are not progressing in terms of activity-related pain and function. Depending on the specific CT findings, a repeat attempt at bone grafting, with the possible addition of bone-graft substitute and/or possible modification of internal fixation, may be warranted to forestall later clinical problems.

Krause et al. imply that trusting plain radiographs that show no indication of fusion failure is not acceptable when patient pain and function do not improve in a timely fashion.  Conversely, they conclude that their findings do not support “the concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well),” because nonunions identified early by CT eventually resulted in worse clinical outcomes. The authors also noted that obesity, smoking, and not working increased the risk of nonunion, corroborating findings from earlier studies.

While advanced imaging such as CT is not necessary in foot/ankle fusion patients who are improving in terms of function, pain, and swelling , this study stresses the importance of achieving union following these fusion procedures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS Reviews Editor’s Choice–Treating ACL Injuries

Cx5bB4PUkAATggw.jpgOne of the observations that I have made during my years in academic medicine is that the more popular a topic appears to be in the literature, the less likely we are to really understand it. After all, if we need to write about it so much, it must mean that there is still much to learn. This certainly seems to be the case with regard to injuries of the anterior cruciate ligament (ACL). ACL injuries are among the most common injuries sustained in the United States. Over 100,000 ACL reconstructions were performed in the United States in 2006, and the annual rate has continued to increase over time. Although some patients have achieved good results after nonoperative treatment, a survey of the American Orthopaedic Society for Sports Medicine showed that the majority of respondents used nonoperative treatment for fewer than 25% of their patients with ACL injuries.

Noyes et al.1 described the so-called “rule of thirds.” According to this rule, one-third of patients with an ACL injury will compensate well with nonoperative treatment (copers), one-third will avoid symptoms of instability by modifying activities (adapters), and one-third will require operative reconstruction (noncopers). Unfortunately, there does not seem to be any way to predict which group an individual patient will fall into. Thus, there is still substantial ambiguity in determining which patients are most likely to benefit from early intervention with ACL reconstruction following injury.

In this month’s issue of JBJS Reviews, Secrist et al. used the literature to perform a comparison of operative and nonoperative treatment of ACL injuries. They noted that only 3 randomized controlled trials have compared operative and nonoperative treatment of ACL injuries and that 2 of those studies involved the use of ACL suturing as opposed to more modern forms of reconstruction. The third study involved only 32 patients. All studies had substantial methodological limitations. The authors concluded that there have been no Level-I studies comparing ACL reconstruction with nonoperative treatment.

In their review article, Secrist et al. attempted to define and evaluate the available data on the natural history of nonoperatively treated ACL injuries and to determine how the functional outcomes and injury risks associated with nonoperative treatment compared with those associated with reconstruction. Moreover, they sought to define prognostic factors and rehabilitation protocols associated with successful operative outcomes. Finally, they compared the outcomes following early versus delayed ACL reconstruction.

However, by the end of the article, one gets the feeling that the authors have “come full circle.” The authors summarize their findings by saying that some patients can cope with a torn ACL and return to preinjury activity levels, including participation in pivoting sports. On the other hand, patients who have an ACL injury along with a concomitant meniscal injury are at increased risk for osteoarthritis, and it is unclear what effect reconstruction of an isolated ACL has on future osteoarthritis risk in ACL-deficient patients who are identified as “copers.”

I suspect that we will continue to see articles on this topic for many years to come. In light of the “rule of thirds” and the additional impact of meniscal injury, the allocation of a particular patient to operative or nonoperative treatment remains unclear.

Thomas A. Einhorn, MD
Editor, JBJS Reviews


  1. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate-deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983 Feb;65(2):163-74 Medline.

JBJS Reviews Editor’s Choice–Open Fracture Care During War

War Wound.jpgInjuries to the musculoskeletal system are among the most common wounds of war. Compared with extremity injuries in the civilian population, injuries sustained in combat tend to be due to high-energy explosions and are associated with a greater degree of contamination and a longer timeline for recovery and healing. Importantly, the sequelae of musculoskeletal injuries sustained during combat tend to lead to more long-term disability than those affecting other organ systems.

In this month’s Editor’s Choice article, Rivera et al. review the current literature on combat injuries of the lower extremity and suggest that explosions are the most common mechanism of injury encountered by deployed service members. While exposure to an explosion does not necessarily result in a specific limb injury, the explosion mechanism does contribute to more severe injuries. Moreover, among service members who sustain open fractures of the tibia, foot, and ankle, infection is a common complication and is associated with more severe soft-tissue injury. As a result, surgeons who are deployed in combat settings are now performing more fasciotomies for limbs that are at risk. However, the outcomes and complication rates associated with these procedures are not well established, and the causes of late amputations are not always clear.

As part of a comprehensive review of this topic, Rivera et al. pose 3 important clinical questions that are ideal for translational research investigation. First, they ask, “What is the best way to manage and transport patients who have severe open fractures in order to minimize infection?” Indeed, while negative-pressure wound therapy (NPWT) appears to be a promising wound-care technique, additional study is needed in order to know how to best augment the standard of care for battlefield medicine. Second, “What is the best way to treat fasciotomy wounds and the late sequelae of the compartment syndrome?” In order to answer this question, a broader understanding of compartment syndrome detection and the indications for surgical treatment are needed. Finally, “What is the best way to select limbs for salvage and to optimize the reconstruction of injured tissues?” This question must explore not only the patient’s perspective but also the multitude of causes that lead to late amputation.

Thomas A. Einhorn, MD
Editor, JBJS Reviews

JBJS Editor’s Choice—Knee Fusion: Not a Safety Net after Infection-Related TKA Failures

In the February 18, 2015 issue of The Journal, Rohner et al. report their experience with knee arthrodesis using an intramedullary rod as the definitive treatment for failed total knee arthroplasties (TKAs) related to infection. They report the results for 26 patients treated between 1997 and 2013 who had undergone an average of 6 ±3 knee procedures prior to arthrodesis.

The outcomes for this cohort of patients are sobering. Persistent infection requiring additional surgery remained in 50% of the patients. The health-related quality-of-life measures and functional outcomes were abysmal, and 73% reported persistent pain at greater than 3 on the VAS. Obesity, high blood pressure, and diabetes were strong predictors of reinfection.

Many of us have taken comfort that knee fusion, by whatever surgical technique, is a reliable “bail out” for the problem of recurrent infection following revision of a loose or infected TKA. Nevertheless, any surgeon who has followed a patient with a knee fusion is fully aware of the functional disability associated with the stiff knee. Difficulties using public transportation and impaired sitting are just two inconveniences that these patients express unhappiness about.

Despite its retrospective design and relatively small number of cases, this report may cause the knee-reconstruction community to reconsider knee arthrodesis and instead attempt further staged revisions of the knee prosthesis. It may even prompt a slightly earlier move toward recommending trans-femoral amputation. It certainly will stimulate further research into infection prevention and into developing more predictable approaches for revising infected TKA prostheses.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

JBJS Reviews Editor’s Choice–Open Tibial Fractures

Orthopaedic surgeons have developed a heightened awareness of the scientific evidence that supports the decisions that they make in the care of patients. Levels of evidence and grades of recommendation have been used in scientific articles in order to frame information in an evidence-based manner. However, despite the substantial strides that have been made in promoting evidence-based practice throughout orthopaedic surgery, some historical dogma still exists and many surgeons do things based on what they were told or taught many years ago. One example is the so-called “six-hour rule,” in which it is considered the standard of care to urgently perform irrigation and debridement of an open tibial fracture within six hours after the time of injury.

Fractures of the tibial diaphysis are among the most common major long-bone fractures treated by orthopaedic surgeons. Up to 24% of these fractures present as open injuries, and a considerable portion are associated with severe soft-tissue compromise. Open tibial fractures receive different levels of treatment based on the severity of the injury according to the Gustilo and Anderson classification system. In the February 2015 edition of JBJS Reviews, Mundi et al. explore the practice patterns and clinical evidence to support four aspects of treatment that are essential to the management of open tibial fractures: irrigation and debridement, antibiotic prophylaxis, fracture stabilization, and wound management.

With regard to irrigation and debridement, although timely treatment within six hours after injury is considered the standard of care, there is insufficient evidence to support this practice. Moreover, the ideal irrigation solution and the optimum pressure of the irrigation are unknown.

Information on the use of antibiotics in the management of open tibial fractures is based on various well-designed studies, so the quality of the evidence to support some of these recommendations is better. Investigators agree that antibiotic prophylaxis should be started as soon as possible after presentation to an emergency department or hospital and that patients should receive antimicrobial coverage against gram-positive bacteria, typically with a first-generation cephalosporin. Gustilo and Anderson type-III injuries require additional antibiotic coverage, and the use of aminoglycosides is indicated, although the optimum regimen has not been established. Local antibiotic administration at the site of the injury (e.g., antibiotic-laden cement beads) is potentially beneficial but is primarily used for patients with type-III injuries.

The optimum time for closure of these wounds has yet to be determined, although primary closure is warranted under specific circumstances. For those injuries that require delayed closure, definitive coverage should not be delayed beyond seven days, even in the setting of negative-pressure wound therapy.

With regard to stabilization, techniques for the operative management of open tibial fractures have evolved and current evidence shows superior outcomes in association with intramedullary nailing as compared with plate fixation. However, there had been a debate regarding reamed versus unreamed intramedullary nailing. Interestingly, a randomized controlled trial was conducted to answer this question, and the results showed that both reamed and unreamed intramedullary nailing are reasonable options for the fixation of open tibial fractures, with the two techniques demonstrating comparable outcomes.

At this time, there remains a need for additional high-quality evidence to clarify the efficacy of specific techniques and treatments. In particular, guidelines detailing the optimal irrigation solution and pressure as well as the ideal duration of antibiotic prophylaxis are needed. Continued efforts to design and organize large-scale randomized clinical trials will be required in order to provide the kind of evidence that orthopaedic surgeons need so that they can provide the best care for their patients.

Thomas A. Einhorn, MD, Editor

JBJS Reviews Editor’s Choice–Patient Activation

As medical practice continues to evolve, one thing that has become clear is that teamwork is a key ingredient for achieving success. In the field of medicine, the goal is improved patient outcomes and the teamwork involves the combined efforts of the patients and their caregivers. Indeed, it has been demonstrated that highly activated patients (i.e., those who take proactive collaborative roles in maintaining their health) incur lower medical costs and achieve improved therapeutic outcomes and greater satisfaction in comparison with less-activated patients.

In this issue of JBJS Reviews, Tzeng et al. take the position that patient activation is a dynamic continuum and that clinicians can boost activation by working together with patients to overcome barriers such as social and environmental disadvantages, low self-confidence, and lack of problem-solving and self-management skills. Thus, clinicians should understand that patient activation can be used to inform and personalize plans of medical care in a way that will foster cooperation between patients and their caregivers.

The recent shift toward consumer-driven health care has led to a need to define and understand the patient’s role in health care. Historically, little attention has been paid to the key factors and research priorities that govern patient engagement. In 2012, the Patient-Centered Outcomes Research Institute brought this concept to national attention by demonstrating that the factors that govern this type of collaboration are specifically required for financial rewards from the Medicare and Medicaid Electronic Health Records Incentive Programs.

Tzeng et al. describe how there are two types of patient activation. The first type is individual patient activation, in which a patient’s ability to handle his or her health and health care is established. In the second type of activation, there is participation from the community. Community activation is a health-promotion strategy in which organizations, companies, and provider groups make a concerted effort to improve health awareness, to plan prevention programs, to allocate resources, and to involve citizens in these processes. There are, however, barriers to patient activation. In particular, the level of patient and community engagement is often lower in populations with minority backgrounds, low incomes, limited education, and poor self-reported health. As an example, Caucasians typically have higher activation levels than African Americans and other minority groups, a manifestation of the fact that activation is associated with social-environmental factors.

For orthopaedic surgeons, integrating patient activation into clinical practice may require substantial change, but the benefits of doing so are substantial. More investigation is required in order to determine the best approaches for different medical specialties and patient populations, but current evidence clearly affirms that the activated patient is healthier and happier.

Thomas A. Einhorn, MD, Editor

JBJS Editor’s Choice—Better Prognoses for Aging Shoulders

We have long been taught that among people fortunate enough to survive into their 80s, 70% to 80% will have a torn rotator cuff— that it’s part of life just like degenerating lumbar discs. These figures were based on cadaveric studies, a study design that comes with a whole spectrum of issues around detection and selection bias.

However, in the January 21, 2015 issue of The Journal, Keener et al. provide us with much more reliable data regarding the progression of asymptomatic rotator cuff tears in a population of 224 subjects. The cohort included people with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the contralateral shoulder. As determined by ultrasound, 118 had full thickness tears, and 56 had partial thickness tears. Importantly, the study also included 50 controls with no ultrasound evidence of rotator cuff tear in one shoulder and painful cuff disease in the contralateral shoulder. Researchers followed the cohort for a mean of more than 5 years.

The good news is that neither age nor gender was found to be related to the risk of tear enlargement. Tear enlargement occurred in 49% of all the shoulders at a median of 2.8 years, and the risk of enlargement was 4.2 times and 1.5 times higher in subjects with full thickness tears, relative to controls and those with partial thickness tears, respectively. Both tear type and tear enlargement were associated with the onset of “new pain,” further assuring us that following our rotator cuff patients clinically is a sound and cost-efficient strategy.

What I found most interesting is that progressive muscular degeneration in the supraspinatus muscle belly, as detected by ultrasound, was associated with tear enlargement. This strengthens our recommendations—to our patients and ourselves—to engage in rotator cuff strengthening as a part of overall resistance training for lifelong maintenance of function and preservation of muscle mass.

So…. to protect our cuff integrity and for innumerable other reasons, back to the gym we go.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

JBJS Editor’s Choice—Is Hot Air in the OR Risky to Patients?

Forced air warming devices are in widespread use in our orthopaedic surgical suites—and for good reason: Hypothermia can be a major factor in poor patient outcomes due to its negative impact on myocardial function, pharmacokinetics, and other aspects of patient physiology. While maintaining normothermia in surgical patients lowers the risk of postoperative surgical site infections, recent literature has raised concerns about an increased risk of infection in arthroplasty cases in which forced air warming was used.

The December 17, 2014 JBJS literature review by Sikka et al. focuses on this conundrum. It is a well-written summary of current knowledge that clearly outlines the deficiencies in the available data. The authors emphasize that the studies yielding both positive and negative findings are in most cases tainted with detection and selection bias related to industry-funded research designs. This is an area that is begging for a large randomized controlled trial.

However, because of the <1% overall incidence of infection following lower-limb arthroplasty, such a trial will require large numbers of patients. Also essential for such an investigation will be an experienced clinical trialist, meticulous methods, and an apriori definition of “infection.” It is doubtful that registry data analysis can adequately determine the efficacy of forced air warming in preventing major intraoperative adverse events or its impact on postoperative infection, but an analysis of all available data would be a good start.

I look forward to future well-designed studies in this area that will further clarify patient benefit as well as risk. In the meantime, Sikka et al. stress the importance of following all manufacturer instructions for use and maintenance of any patient-warming device.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

JBJS Reviews Editor’s Choice–Failed Total Knee Arthroplasty

Perhaps more than any other advance in orthopaedic surgery, total joint arthroplasty has improved the lives of millions of patients. Originally introduced in the form of hip replacement, nearly all of the major joints of the musculoskeletal system can now undergo arthroplasty, and total knee arthroplasty has established itself as one of the most successful interventions for reducing pain and improving function and quality of life. All total joint arthroplasties are associated with a risk of failure, and it is believed that, with the exception of the oldest patients, most individuals who undergo an arthroplasty will require a revision at some point during their lifetime. With total knee arthroplasty, advances in implant materials and design as well as operative technique have increased implant longevity and decreased the rate of revision to <5% within ten years.

As is typical of a successful intervention, surgeons who perform total knee arthroplasty recognize the need or opportunity to “push the envelope.” There is great demand for offering knee arthroplasty to younger, more active patients, and, in doing so, it is projected that the number of revision procedures will grow from the current annual incidence of 38,000 up to 270,000 by the year 2030. Thus, understanding the causes of failure will be essential for guiding future strategies.

In this month’s article by Bou Monsef et al., a systematic approach to identifying mechanisms of failure and appropriate treatment protocols for failed total knee arthroplasty are introduced. The authors make the important point that avoiding operative intervention before a diagnosis is made, even in cases of pain with no clear etiology, is essential. Individual discussions on the roles of infection, loosening and component failure, instability, stiffness, patellofemoral complications, and even neuromas are presented and placed in their proper perspective.

Indeed, one of the greatest frustrations in orthopaedic practice is the inability to identify the causative factors for a condition. The failure of a total knee arthroplasty may be associated with one or more contributing factors, including rare and unusual conditions such as the formation of heterotopic bone, the development of complex regional pain syndrome, the occurrence of hemarthrosis, and even hypersensitivity to certain metals. Interestingly, up to 17% of the general population expresses some sensitivity to the metals used in total knee implants such as nickel, chromium, and cobalt.

Failure of total knee arthroplasty can be devastating to the patient, but early diagnosis and careful systematic analysis of the potential etiologies can lead to a favorable outcome. This article provides a clear and concise approach to this problem and is a “must read” for surgeons who perform this operation now and the residents and fellows who will be caring for these patients in the decades to come.

Thomas A. Einhorn, MD, Editor

JBJS Editor’s Choice–Distal Radius Fractures in Older Men: Why So Much Publicity?

In my 20-plus years serving as a deputy editor and editor of JBJS, I have never seen the kind of media interest in research published in The Journal that the Harper et al. study on distal radius fractures in older men has received.

This well-done retrospective evaluation of 95 males and 344 females who were treated for a distal radius fracture at a single institution has been discussed in multiple forums and media outlets, including the national newswire services, scientific and clinical blog sites, and health reports on local and national TV newscasts.

One conclusion from the Harper et al. analysis was that males older than 50 who had a distal radius fracture are receiving far worse follow-up care compared to females with the same characteristics in terms of bone-mineral density testing and subsequent pharmacologic treatment to prevent future fractures. For example, an older male with a fragility-caused distal radius fracture is nearly 10 times less likely to undergo bone-density testing than a woman with the same fracture. What is so newsworthy about this finding as to prompt headlines such as “Gender Bias in Osteoporosis Screening”?

My hypothesis is that orthopaedic research has focused too much on procedural-based interventions. When research such as the Harper et al. study extends beyond developing new therapies to matters of population health and application of evidence-based therapies, the public pays especially close attention. Previous OrthoBuzz posts by my JBJS predecessor Vern Tolo, MD and JBJS Reviews Editor-in-Chief Tom Einhorn, MD have called on clinicians to take a more aggressive approach toward primary and secondary prevention of fragility fractures. JBJS commentator Douglas Dirschl, MD says that the gender disparity revealed by Harper et al. “should shock the medical community into improved performance.”

Orthopaedic surgeons are increasingly working in teams consisting of family physicians with additional musculoskeletal training, radiologists, anesthesiologists, nurses, PTs, OTs, and athletic trainers. As our field expands its scope to “musculoskeletal health, prevention, and treatment” and away from exclusively invasive interventions, let’s continue to invite the public along. Based on the media coverage of the Harper et al. study, the public appears to be a willing partner in our attempts to reduce the risk of fragility fractures.

Do you think including preventive and population-health perspectives is the right direction for our field? Send us a comment of support or a dissenting view by clicking on the “Leave a Comment” button in the box to the left.

Marc Swiontkowski, MD

JBJS Editor-in-Chief