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Predicting Failure of Femoral Neck Fixation

Femoral Neck Fracture for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in the Journal of Orthopaedic Trauma.

With many problems in orthopaedics, the best management options are still being debated. The treatment of femoral neck fractures is one such problem. Surgeons have several available options: cancellous screws (CS), a sliding hip screw (SHS), hemiarthroplasty, and total hip arthroplasty. The recently completed Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) randomized trial sought to offer insight on those treatment modalities.1 The study enrolled 1,079 patients with low-energy femoral neck fractures and randomized them into treatment with CS or SHS.

In a follow-up study published in the May 2018 edition of the Journal of Orthopedic Trauma, Sprague et al. analyzed FAITH data to identify predictors of revision surgery during 24 months after surgical fixation of a femoral neck fracture.2 Based on previously published studies, the authors identified 15 factors a priori that may be associated with revision surgery . Among the more than 800 patients in the FAITH cohort who had complete follow-up data, 191 (23%) underwent revision surgery and were included in the analysis. Proportional hazard modeling identified 5 factors associated with revision surgery: female sex (hazard ratio [HR], 1.79), body mass index (HR, 1.19—a 19% increased risk of revision for every 5-point increase in BMI), displaced fracture (HR, 2.16), Pauwels type III configuration (HR, 2.13 relative to type II), and poor implant positioning (HR, 2.70). In addition, prefracture dependence on assistive devices for ambulation was significantly associated with a risk of conversion to arthroplasty (p = 0.04), although a hazard ratio was not reported.

These important findings may help guide our decision making for the treatment of femoral neck fractures. First, male patients may be better candidates for surgical fixation of neck fractures than female patients, which probably relates to sex differences in bone density. Thinner patients also may be better candidates for femoral neck fixation, while arthroplasty may be the more reliable option for high-BMI patients.

Second, we have to pick the right fractures to fix. As is well described elsewhere in the literature, a more vertical fracture line (>50°) is more likely to fail with fixation. Additionally, patients with displaced fractures face a significantly higher risk of revision surgery and may be poor candidates for fixation.

Arguably, the most important modifiable risk factor for revision surgery is surgical technique. Unfortunately (and fortunately), in the FAITH study there were too few malreductions to investigate this variable in detail. However, poor implant positioning—defined as prominent screws at the lateral cortex, screw penetration, and lag screws positioned too high—was strongly associated with an increased risk of revision surgery.

It goes without saying, but well-placed implants perform better.

Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.

References

  1. Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017;389(10078):1519-1527.
  2. Sprague S, Schemitsch EH, Swiontkowski M, et al. Factors Associated With Revision Surgery After Internal Fixation of Hip Fractures. J Orthop Trauma. 2018;32(5):223-230.

Addressing the Gender Gap in Orthopaedics

Female Orthos for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Megan Conti Mica, MD, in response to the 2018 Medscape Orthopaedist Compensation Report.

In a recently published Medscape survey looking at orthopaedic compensation,  orthopods were the second-highest paid specialists overall. Despite that, only 51% of orthopaedist respondents to the Medscape survey felt they were fairly compensated. My question to you is: How fairly compensated would orthopods feel if that second-highest salary was decreased by $150,000 annually without reason?

While the reported overall wage gap between female and male physicians is more than $50,000 annually1, the Medscape survey found that the gender wage difference for orthopaedic surgeons was $143,000 annually—adding injury to insult. That annual gap would amount to $4 million of lost wages for women over a 30-year career as an orthopaedic surgeon.

Why does medicine in general and orthopaedics in particular have a gender gap?  Is it because male surgeons have better outcomes than female surgeons?  Not according to a 2017 study that found that patients of female surgeons experienced lower death rates, fewer complications, and fewer 30-day readmissions to the hospital, compared with patients of male surgeons.2 While I do not believe that gender alone makes one a better surgeon, I do believe that gender diversity within our field is imperative.

What is more disheartening is it seems no one with the power to make change is doing anything to close the gap. In 2009, only 4% of the AAOS fellows were female. Honestly, I cannot blame women for not trying to join the “boys club.”  If someone told you that you would be a distinct minority in your profession, make less, and have to work harder, most rational human beings would find a different career.  If we want more women in orthopaedics, we need to understand that the gender wage gap is just the surface of a bigger issue.

I challenge everyone (men and women) to do better. Help your female partners. Be more attentive and mentor female surgeons. Support women when they speak up, and champion for them when they don’t. The attributes that make a great orthopaedic surgeon—love of and dedication to this great specialty—are gender-neutral.

Megan Conti Mica, MD is a hand and upper-extremity surgeon at the University of Chicago Medical Center and a member of the JBJS Social Media Advisory Board.

References

  1. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284
  2. BMJ 2017;359:j4366, Published 10 October 2017. doi: 10.1136/bmj.j4366

Horseshoes and Total Knee Arthroplasty

TKA Alignment for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent JBJS article.

The old adage that “close only counts in horseshoes” may also apply to total knee arthroplasty (TKA). Much attention has been paid to coronal alignment during TKA based on conventional wisdom that prosthetic durability and patient function are strongly dependent on that parameter. To re-check that hypothesis, in the March 21, 2018 issue of JBJS, Abdel et al. evaluated the influence of coronal plane alignment on implant survival by analyzing results from a large cohort of patients who underwent primary TKA 20 years ago.

In 2010, Abdel’s group reviewed a consecutive series of 398 primary cemented TKAs done between 1985 and 1990. Knees were divided into 2 groups based on their mechanical alignment as measured using a full-length hip-knee-ankle radiograph. Knees in the “aligned group” (n = 292) were defined as having alignment within 0° ± 3° of the mechanical axis, and knees in the “outlier group” (n = 106)  were defined as having alignment >3° in varus or valgus. Implant survival was evaluated based on the need for revision, and the specific indications for revisions were recorded.

In the current study, at 20 years of follow-up, the authors found revision rates that were not significantly different between the same 2 groups—19.5% in the mechanically aligned group and 15.1% in the outliers. Multivariate analysis controlling for patient age and BMI did not demonstrate any implant survivorship benefit for the mechanically well aligned group as compared to the outliers.

This study seems to call into question the dogma that a neutral mechanical axis protects against mechanical failure. The effort, time, and money spent on techniques and devices to improve coronal plane alignment by a few degrees (i.e., computer navigation, custom jigs, and robotics) may not translate into meaningful improvements in patient outcomes.

It is important to note that in this group’s 2010 study evaluating the same cohort, 66% of knees in the outlier group were only 4° shy of neutral and only 12% (13 knees) were >6° off. So, while we should still strive for neutral mechanical alignment, it seems that we may miss the neutral mark by a few degrees without harming our patients.

Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.

Aspirin Noninferior to Rivaroxaban for Anticoagulation after Joint Replacement

Aspirin for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Amir Khoshbin, MD in response to a recent randomized trial in the New England Journal of Medicine.

The ideal anticoagulation protocol for patients who have received a total knee or hip replacement remains controversial. Results from the recently published “Extended Venous Thromboembolism Prophylaxis Comparing Rivaroxaban to Aspirin Following Total Hip and Knee Arthroplasty (EPCAT) II” trial add some clarity to this topic.

This large double-blind, randomized noninferiority trial compared two outpatient anticoagulation regimens after elective unilateral primary or revision hip or knee arthroplasty. Almost 3,500 patients were enrolled, and they all received 10 mg of rivaroxaban daily until postoperative day five. After that, 1,707 patients were randomized to receive 81 mg of aspirin daily, while the remaining 1,717 patients received 10 mg of rivaroxaban daily. Per previous recommendations, total knee arthroplasty patients received anticoagulation for a total of 14 days, and total hip arthroplasty patients continued anticoagulation for 30 days.

Twelve patients in the rivaroxaban group (0.7%) had a venous thromboembolism event in the 90-day postsurgical period, versus 11 patients (0.64%) in the aspirin group (p >0.05). In terms of complications from anticoagulation treatment, 5 patients (0.29%) in the rivaroxaban group and 8 patients in the aspirin group (0.47%) had a major bleeding event (p >0.05).  It is worth noting that there were multiple different implants, approaches, and perioperative protocols followed in the study. Also, very few patients with a history of venous thromboembolism (81 patients, 2.4%), cancer (80 patients, 2.3%) or smoking (319 patients, 9.3%) were included in the study. These patients would be considered at higher risk for venous thromboembolism after joint replacement.

These limitations notwithstanding, the results from prophylaxis with aspirin after an initial five days of rivaroxaban were not significantly different from results with continued rivaroxaban. Institutional prices vary, but in this time of bundled care, the financial implications of studies like this one could be great. Anecdotally, in our institution the price of rivaroxaban is 140 times that of aspirin.

This is not the first study whose findings support the use of aspirin for venous thromboembolism prophylaxis, but it is one of the largest. It appears that such findings are starting to change the practice of some orthopaedic surgeons. We expect that additional large studies will provide further insight into this question.

Amir Khoshbin, MD is an assistant professor of orthopaedics at the University of Toronto and a member of the JBJS Social Media Advisory Board. He can be reached at khoshbinam@smh.ca.

Chondroitin Sulfate Similar to Celecoxib in Easing Pain of Knee OA

Rich Yoon Headshot.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD, in response to a recent study in Annals of the Rheumatic Diseases.

European investigators recently reported on a trial comparing the efficacy of pharmaceutical-grade chondroitin sulfate (CS) (800 mg/day) with the NSAID celecoxib (CX) (200 mg/day) and placebo in more than 600 patients with painful knee osteoarthritis (OA).

In this well-designed, well-executed, double-blinded, 3-armed trial, investigators tracked patient pain scores at baseline and at 1-month, 3-month and 6-month intervals. This trial was characterized by strict adherence to blinded protocols, high levels of patient adherence, and meticulous review of patient diaries and adverse-event reports.

Patients in both the CS and CX groups experienced significantly greater pain relief when compared to those in the placebo group at every follow-up time point. In addition to tracking pain via the visual analogue scale (VAS), the investigators included the Lequesene index (LI)—which integrates both pain and function—along with the Minimal-Clinically Important Improvement (MCII) scale. While CX and CS were not superior/inferior to one another, both active treatments provided significant pain improvements relative to placebo according to all three measurements at all time points.

These findings showing the efficacy of pharmaceutical-grade CS are important for orthopaedic surgeons, rheumatologists, and general practitioners. Nonoperative management of knee OA remains an important modality that requires a multimodal approach, typically including NSAIDs and/or acetaminophen. These results suggest that there’s another safe medication that may prove especially helpful for OA patients who cannot tolerate NSAIDs or acetaminophen due to kidney, gastrointestinal, cardiovascular, and/or liver issues.

Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.

9 Tips to Excel with MIPS

Weisstein Headshot for O'Buzz.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.

MIPS—the Merit-based Incentive Payment System—is still a mystery to many orthopaedic surgeons. But it can have a big positive or negative impact on your practice.

MIPS is a federal improvement-incentive program consisting of Quality, Resource Use, Clinical Practice Improvement, and Advancing Care components. To demonstrate excellent performance (and reap the associated rewards), physicians can choose the activities and measures that are most meaningful for their practice. Weights are assigned to each category based on a 1 to 100 point scale. In 2017, the transition year, weights are as follows: Quality-60 percent, Cost-0 percent, Improvement Activities-15 percent and Advancing Care Information-25 percent.

I often hear a lot of grumbling from colleagues about their electronic health record (EHR) systems as one of the major causes of physician burnout. However, implementing the right technology will help you excel under this new reimbursement model.

Here are 9 MIPS tips related to EHRs:

  1. Choose the Quality benchmarks that best fit your practice. You need at least 20 eligible cases per Quality measure. Go to the CMS website and select benchmarks that have established measures.
  2. Report Quality for an entire year or over 90 days.
  3. Make sure your EHR has built-in dashboards that enable you to keep an eye on your composite score in near real-time, from day to day.
  4. Be sure that the EHR you select captures data being entered at the point of care and can enable this data to be used for multiple purposes.
  5. Get a head start on the Advancing Care component. Selecting an EHR vendor with successful Meaningful Use (MU) attestations is critical.
  6. Earn bonus points via specialty registries and Clinical Improvement Activities.
  7. Make sure your EHR allows you to compare your performance with that of your peers using analytical tools.
  8. When engaging in Clinical Improvement Activities, follow guidelines based on your specific practice size.
  9. Submit only the required number of Clinical Improvement Activities for the given measurement year, because the following year, you may need to pick a different activity.

With the shift to MIPS and value-based care, orthopaedic surgeons and their teams can thrive by adapting and utilizing technology that fits within their workflows and that helps them understand how they are performing in real time, both within their own practices and compared with their peers nationwide.

Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.

Guest Post: Is There a Role for LIPUS in Bone Healing?

LIPUS.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from E. Scott Paxton, MD, in response to a recent “Rapid Recommendation” in The BMJ.

An international panel convened by The BMJ recently issued a “Rapid Recommendation” that strongly recommends against using low-intensity pulsed ultrasound (LIPUS) in patients with fracture or osteotomy because the treatment doesn’t improve functional recovery or pain.1

The systematic review on which the recommendation was based reviewed 26 trials of nearly 1600 patients with fracture or osteotomy who were randomized to either LIPUS or sham/no device.2 The authors concluded with moderate to high levels of certainty that the treatment had little effect on the time patients could return to work, time to full weight-bearing activity, pain levels, future operations, or time to radiographic healing.

In 2009, Busse et al. performed a similar meta-analysis, concluding that “evidence for the effect of low intensity pulsed ultrasonography on healing of fractures is moderate to very low in quality and provides conflicting results.”3 This analysis only included 13 trials, however. Then, in 2016, Busse et al. published results from the TRUST study,4 a blinded, randomized controlled trial of 501 patients from 43 North American academic trauma centers who had a fresh tibial shaft fracture treated with intramedullary nailing. The authors based their sample size calculations on the minimal clinically important difference on the SF-36 PCS, as this was a co-primary outcome. The authors found no improvement in radiographic healing time or functional recovery with the use of LIPUS. However, the authors noted that only 1 nonunion occurred among 195 sham-treated patients, demonstrating that this group was at extremely low risk for nonunion at baseline.

Including the TRUST trial in the 2017 meta-analysis of LIPUS led Schandelmaier et al. to the aforementioned conclusions and informed the strong BMJ Rapid Recommendation against the use of LIPUS for patients with any bone fracture or osteotomy. However, this recommendation was based in large part on the TRUST trial, which was unable to directly assess the effectiveness of LIPUS on reducing nonunion rates because of the almost universal healing of the fractures studied.

The BMJ Rapid Recommendation states “there was high quality evidence showing a lack of benefit in accelerating healing for fresh fractures; thus it is unlikely that LIPUS would improve outcomes in patients with non-union.” However, the effect of LIPUS on preventing nonunions in fractures known to have high nonunion rates or on treating established nonunions will require further high-quality studies looking at those patients specifically.

Scott Paxton, MD is an assistant professor in the Department of Orthopaedic Surgery at the Warren Alpert Medical School at Brown University and a fellowship-trained shoulder and elbow surgeon at University Orthopedics in Providence, Rhode Island.

References

  1. Poolman RW, Agoritsas T, Siemieniuk RAC, et al. Low intensity pulsed ultrasound (LIPUS) for bone healing: a clinical practice guideline. BMJ. February 2017:j576-j576. doi:10.1136/bmj.j576.
  2. Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ. 2017;356:j656. doi:10.1136/bmj.j656.
  3. Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ. 2009;338:b351. doi:10.1136/bmj.b351.
  4. TRUST Investigators writing group, Busse JW, Bhandari M, et al. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016;355:i5351. doi:10.1136/bmj.i5351.

Guest Post: “Telemedicine” for Knee OA Works

telerehabOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to a recent study in the Annals of Internal Medicine.

Few disease processes are as prevalent within the United States as hip and knee osteoarthritis (OA).  While OA is commonly thought to be a disease of older age, the reality is that over half of all individuals with knee arthritis are younger than 65. While some of those individuals will eventually go on to have a knee arthroplasty, before that, most OA patients try various other treatments in an effort to decrease pain and increase function.  Medications such as NSAIDs and others are certainly a part of these treatment efforts, but nonpharmacologic treatments are also widely recommended.

However, as Bennell et al. clearly state in their Annals article, patients face multiple barriers to the implementation of these nonoperative, nonpharmacologic modalities, including cost and transportation to relevant clinical specialists. The authors used these barriers as the rationale for a randomized trial in which an intervention group of knee OA patients received Internet-based educational material, online pain-coping skills training, and videoconferencing with a physiotherapist who provided individualized exercises for each patient. A control group received only the educational material.

At 3 and 9 months, both groups showed improvements in pain and function, but the intervention group had significantly greater improvements than the control group.  More importantly, the people in the intervention group largely adhered to all online programs on their own and were very satisfied with the prescribed treatments, especially the video-based physiotherapy component.

Internet-based health interventions are certainly not new. However, my suspicion is that 20 years from now we will look back and wonder why we did not use them more often. They are self-directed, cost-effective, reproducible, and available to any of the 87% of Americans over the age of 50 who, according to the Pew Research Center, use the Internet. These online interventions require no driving to an office, and patients can easily track their own progress by seeing how many modules they have completed.

While there are certainly limitations to the findings from Benell et al., as an accompanying editorial by Lisa Mandl, MD points out, the study serves as a very strong proof of concept that should be expanded upon. Dr. Mandl herself proclaims that “these results are encouraging and show that ‘telemedicine’ is clearly ready for prime time.”

With the number of ways we “stay connected” always increasing, it seems important for orthopaedists to learn how to use these technologies to benefit our patients.  Doing so may require some adjustments, but the ultimate goal of improving the quality of life for our patients warrants whatever creativity and open-mindedness might be necessary.

Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.

Appropriate Use Criteria for Carpal Tunnel Syndrome

Benson Headshot.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.

Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.

It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.

The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”

However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.

For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.

But perhaps the most compelling question is — why do we need an AUC app in the first place?  Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories?  And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.

However, there is another, critically important theme to the AUC story.  Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide.  As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.”  If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.

With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome.  More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.

Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.

Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.

Guest Post: Single-Stage Revision for Failed Shoulder Arthroplasty Is Effective

TSA Infection.gifOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD.

Shoulder arthroplasty continues to grow in popularity, and as the number of shoulder arthroplasties rises, so will the number of revisions. Infection is one major reason for shoulder arthroplasty failure, and Propionibacterium has been increasingly recognized as a major culprit.

However, Propionibacterium infection is difficult to diagnose. Despite improved detection techniques, diagnosis at the time of revision remains elusive because obvious signs of acute infection are often absent. The need to perform explantation in the setting of clinically apparent periprosthetic infection is obvious, but the appropriateness of single-stage revision with antibiotic treatment in shoulders with only apparent mechanical failures remains questionable.

Hsu et al. attempted to address this question in a study published in the December 21, 2016 issue of JBJS. The group retrospectively reviewed the outcomes of 55 shoulders that underwent revision arthroplasty due to continued pain, stiffness, or component loosening without obvious clinical infection. Mean follow up was 48 months. At least five cultures were obtained intraoperatively during each revision, and each case was treated with antibiotics as if were truly infected until the final culture results were received after three weeks. Shoulders were revised to either hemi-arthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty.

Hsu et al. analyzed outcomes according to two groups: the positive cohort (n=27), where shoulders had ≥ 2 cultures positive for Propionibacterium, and the control cohort (n=28), where shoulders had either 0 or 1 positive culture. The two groups were compared by before- and after-revision performance on the simple shoulder test (SST) and pain outcome scores.

Both groups improved postoperatively based on these patient-reported outcome measures, and no significant difference was found between the two groups. Three patients in each group required a return to the OR. Gastrointestinal side effects were the most commonly reported complication from prolonged antibiotic administration.

This study design was limited by its retrospective nature and the lack of a two-stage revision treatment comparison group. Furthermore, this study included only patients with no signs of clinical infection, and the findings may not be applicable to patients with perioperative signs of infection. The study also incorporated three revision surgery implant options, which could have influenced postoperative SST and pain scores. Larger, multicenter controlled trials will be needed to produce a more definitive answer to this complicated question.

Still, there are clear benefits of single-stage revision over two-stage revision, especially with regard to operative time, anesthesia risks, and patient recovery. Given the wide antibiotic sensitivity profile of Propionibacterium and these initial results from Hsu et al., single-stage revision with appropriate antibiotic therapy may be suitable for patients undergoing revision shoulder arthroplasty in the setting of suspected Propionibacterium infection.

Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will complete a hand fellowship at the University of Chicago in 2017-2018.