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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

JBJS Reviews Editor’s Choice–Graduate Medical Education in Orthopaedics

Surgical training throughout the surgical subspecialties has typically followed a so-called apprenticeship model. Experience has been measured on the basis of case log documentation, and competency has been determined by senior mentors. Recently, a paradigm shift in medical education has led to an increasing emphasis on competence—specifically, competence with regard to operative skills, surgical knowledge, professionalism, and the use of assessment tools that can provide credible, accurate, reproducible, and transparent forms of evaluation. Indeed, medical education has become more complex, and the delivery of excellence in education has become more difficult. As an example, restrictions imposed by duty-hour limits and requirements for onsite direct supervision by teachers and mentors has changed the education experience.

Residents-in-training are now required to demonstrate proficiency and knowledge as well as performance in six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. As of July 1, 2013, the Accreditation Council for Graduate Medical Education (ACGME), in conjunction with the American Board of Orthopaedic Surgery and the Residency Review Committee for Orthopaedic Surgery, has implemented the Orthopaedic Surgery Milestone Project, which includes new requirements for training and the assessment of motor skills during basic orthopaedic education.

The introduction to these and other measures such as simulation is rapidly improving orthopaedic medical education. The article by Samora et al. in the November 2014 issue of JBJS Reviews provides a clear window into the immediate future of graduate medical education in orthopaedics. I strongly encourage you to read this article and to be familiar with its contents. Simply stated, it is the way of the future.

Thomas A. Einhorn, MD, Editor

Editor’s Choice—JBJS Reviews, October 2014

Technological advances in orthopaedic surgery occur steadily and incrementally. However, every so often, something comes along that really changes orthopaedic practice. Such is the case with the introduction of reverse shoulder arthroplasty, which is a unique, novel procedure that can be used to treat a variety of conditions affecting the shoulder. In this month’s issue of JBJS Reviews, George et al. review the use of reverse shoulder arthroplasty for the treatment of proximal humeral fractures.

Proximal humeral fractures, particularly those that occur in osteoporotic bone, can be complex and difficult to manage. While the majority of these fractures can be successfully treated with initial mobilization in a sling followed by return to activities, three and four-part fractures often are associated with poor functional outcomes, including nonunion, malunion, posttraumatic glenohumeral arthritis, and stiffness. Thus, operative interventions such as closed reduction and percutaneous pinning, open reduction and internal fixation with locked or unlocked plates, and locked intramedullary nailing are available options. However, because of the difficulty associated with reduction of three and four-part fractures, open reduction and internal fixation is associated with a high rate of complications.

Nearly sixty years ago, Neer described the use of hemiarthroplasty for the treatment of three and four-part fractures of the proximal part of the humerus. Implants and techniques steadily improved over the ensuing six decades, but the introduction of reverse shoulder arthroplasty may represent a major step forward. In the article by George et al., the use of reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have led to good results after short and intermediate-term follow up. Malunion or nonunion of the tuberosities did not affect the functional result after reverse total shoulder arthroplasty as much as it did after hemi-arthroplasty, but it did lead to decreased postoperative external rotation.

The long-term outcomes of reverse shoulder arthroplasty for the treatment of these fractures still have not been well established, so we probably should not rush to change our practice on the basis of this article alone. Indeed, since the results have been shown to deteriorate as early as six years postoperatively, reverse shoulder arthroplasty should be reserved for older patients and should be avoided in younger patients. Reverse shoulder arthroplasty can be used for the treatment of rotator cuff arthroplasty and recently has gained popularity for the treatment of severe proximal humeral fractures. This article provides a thorough yet concise overview of the application of this novel technique and implant to the treatment of these difficult and complex injuries.

Thomas A. Einhorn, MD, Editor

Does “Prehab” Lower Episode-of-Care Costs in TJA?

Many orthopaedic surgeons still believe that physical therapy (PT) services simply add to the total cost of care without improving patient outcomes. During my orthopaedic education, several knowledgeable attending surgeons said patients can be shown exercises in the orthopaedic clinic and do them on their own to avoid the increased expense of PT services. This belief extended to preoperative PT (“prehab”) to prepare patients for joint-replacement procedures. Until now, the impact of prehab on the total cost of care had not been rigorously evaluated.

In a well-designed study in the October 1, 2014 edition of The Journal, Snow et al. investigated whether preoperative PT affected total episode-of-care cost for hip- and knee-replacement procedures. They used CMS (Centers for Medicare & Medicaid Services) data from 169 urban and rural hospitals in Ohio and gleaned 4733 complete records to answer the question. The outcome measures of interest were utilization of post-acute care in the first 90 days after the procedure and total episode-of-care costs. The study defined post-acute care as admission to a skilled nursing facility, use of inpatient rehabilitation services, or use of home health services.

Nearly 80% of patients who did not receive preoperative PT services utilized post-acute care services, compared with 54% of patients who did receive prehab services. This resulted in a mean cost reduction of $871 per episode (after adjusting for age and comorbidities), with much of the savings accruing from decreased use of skilled nursing facilities. In their discussion, the authors note that prehab in this study generally consisted of only one or two sessions, and they therefore suggest that “the value of preoperative physical therapy was primarily due to patient training on postoperative assistive walking devices, planning for recovery, and managing patient expectations, and not from multiple, intensive training sessions to develop strength and range of motion.”

So it seems that prehab can reduce the overall cost of care in the setting of joint replacement.  Further investigations using commercial insurance datasets to supplement this CMS data will be useful in developing treatment protocols and policies in this age of global payments for episodes of care.

Marc Swiontkowski. MD, Editor-in-Chief, JBJS

Editor’s Choice—JBJS Reviews, September 2014

It would be an understatement to suggest that the practice of medicine has changed during the past ten years. Indeed, every physician can think of a number of things that have impacted his or her practice. However, among the positive changes that have affected how we treat patients, evidence-based medicine ranks high on the list.

Evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patient values.” Those who support evidence-based medicine note that it will prevent the bias that exists among health-care professionals who frequently base clinical decisions on custom and practice. Hence, the growth of evidence-based medicine along with the desire among clinicians to reduce variations in health-care delivery has had an important and positive impact on health-care practice and policy. Simply stated, the principles of evidence-based medicine serve as a means of decreasing variation in health-care delivery and improving patient outcomes.

The history of evidence-based medicine is interesting and is well covered in the article by David Jevsevar in the September 2014 issue of JBJS Reviews. Concepts and terms are defined, and the findings of research on health-care disparity are discussed. Clearly, the randomized controlled trial (RCT) has become the so-called gold standard in research methodology because of its ability to minimize confounding between patient groups. However, Dr. Jevsevar notes that there are concerns regarding the use of RCTs in the practice of medicine, including their expense as well as the time required for patient recruitment, data analysis, and study completion. As a result of these costs and challenges, most RCTs are now funded by industry, raising concerns about the potential external sources of bias.

This article also touches on other important concepts related to evidence-based medicine in clinical practice policy, such as the propagation and control of conflicts of interest, shared decision-making between physician and patient, and the development of best-practice applications to address the individual needs of and risks to each patient. Finally, it is apparent that the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010 introduces important and vast changes in access to the U.S. health-care system. Designed to address the unsustainable growth in federal spending and the depletion of the Medicare trust fund that is predicted to occur by 2026, this legislation represents an attempt to “bend the cost curve” by showing the increase in annual health-care expenditures. It further makes the point that the absence of an essentially controlled U.S. health-care system creates a potentially large research laboratory promoting study opportunities to investigate the delivery of high-quality, evidence-based care. Thus, the opportunity for orthopaedic surgeons to become advocates for their patients, to take a leading role in shaping the future of evidence-based medicine, and to do so in a way that generates costs that our nation can afford presents a real opportunity to positively shape the future of orthopaedic practice.

Thomas A. Einhorn, MD, Editor, JBJS Reviews

Editor’s Choice—Essential Surgical Techniques – September 2014

O’Driscoll et al. have included 13 videos in their excellent description of a safety-driven technique for arthroscopic arthroplasty of the elbow. While detailing a four-step process for both the anterior and posterior compartments, in eight of the videos, these authors simultaneously display both the exterior surgical field and the intra-articular arthroscopic view with a “picture-in-picture” format. Viewers can thus see what camera and instrument maneuvers the surgeon is performing to achieve the arthroscopic views and surgical goals. Furthermore, the technique videos are “chaptered” so viewers can easily locate, replay, and study specific details at their leisure.

Edward Y. Cheng, MD, Editor, Essential Surgical Techniques

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves.

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves. Source: JBJS Essential Surgical Techniques (3/3/e15)

Editor’s Choice: Advanced Diagnostics for Carpal Tunnel Syndrome–How Come?

In the Sept. 3, 2014 issue of The Journal Fowler et al. elegantly compare the accuracy of ultrasound for confirming the clinical diagnosis of carpal tunnel syndrome with the current standard of electrodiagnostic testing. In a very well-designed trial using the validated CTS-6 patient-reported outcome tool as the reference standard, they determined 90% diagnostic specificity and 89% sensitivity for ultrasound, with a corresponding 80% specificity and 89% sensitivity for electrodiagnostic testing. In this experimental design, high-volume practitioners administered the diagnostic tests so there is a caveat: the reliability of both ultrasound and electrodiagnostic testing is probably dependent on practitioner experience.

The study clearly shows that in patients with positive CTS-6 results and no signs of radiculopathy or polyneuropathy, ultrasound is as good as electrodiagnostic testing at confirming the diagnosis–and more comfortable for the patient. But the findings also beg a question: Do we really need any adjunctive testing for this group of patients, who I think represent the majority of those presenting with carpal tunnel syndrome symptoms? Wouldn’t the patient-reported symptoms and physical-exam results that are captured in the CTS-6 be sufficient?

I believe most of us agree that a careful history and physical exam should always form the basis for most diagnoses in orthopaedics. Carpal tunnel syndrome has a well-clarified anatomic basis and a very effective surgical treatment. There may occasionally be a role for conservative care but it is often ineffective, and patients should be counseled carefully about the limited efficacy of splints and corticosteroid injections. For most patients in whom this diagnosis is strongly suggested by history and exam, advanced testing is not needed and only adds to patient and system costs. By ordering these tests only for complex cases in which the diagnosis or severity of impairment is unclear, we will be improving patient outcomes while lowering the overall cost of care. That in turn will help us achieve the “triple aim” of access, good outcomes, and lower cost.