Archive | Guest Post RSS for this section
June 13, 2018  

Shoulder Arthroplasty: Doxy + Cefazolin No Better than Cefazolin Alone Against P. Acnes

Doxycycline for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD, in response to a recent study in JBJS.

Propionibacterium acnes (now called Cutibacterium acnes, according to an updated classification) is a ubiquitous microbe in the setting of shoulder surgery and is a well-established cause of indolent infection and prosthetic loosening1,2.  In 2016, JBJS published a study by Hsu et al. investigating single-stage revision shoulder replacement in patients with subclinical infection, and the authors reported that almost half of the patients had >2 positive cultures for P. acnes3.  However, the exact consequence of positive cultures at the time of primary surgery is unknown, and the efficacy of specific antibiotic prophylaxis against this microbe remains unclear.

In the June 6, 2018 issue of JBJS, Rao et al. randomised 56 patients scheduled to undergo a primary anatomic or reverse total shoulder replacement to receive either preoperative cefazolin alone (n=27) or a combination of cefazolin and doxycycline (n=29) 4.  All patients had standard skin preparation at the time of surgery with both alcohol and chlorhexidine.

The primary outcome measure was ≥1positive culture after 14 days of incubation from either superficial and/or deep-tissue samples taken intraoperatively. The authors deemed that a decrease of 50% in the positive culture rate would be clinically significant. However, they found no significant difference between the groups in terms of the primary outcome measure (p=0.99).  The authors carried out a secondary analysis to determine which other factors might be associated with ≥1 positive P. acnes culture and found that younger age, male sex, and a lower Charlson Comorbidity Index were predictive.  Although this study was potentially underpowered, it demonstrated that in patients undergoing primary shoulder arthroplasty, preoperative doxycycline does not significantly reduce the prevalence of positive culture rates for P. acnes.

These findings are similar to those found in previous research and should lead us to question whether preoperative antibiotics aimed specifically at preventing P. acnes infection associated with shoulder arthroplasty are truly useful. P. acnes infections are difficult to detect both clinically and via culture—which makes any intervention difficult to measure, especially in a potentially underpowered study. Consequently, larger studies in this area would help to more definitively determine whether preoperative antibiotics aimed specifically at P. acnes decrease infection rates or, instead, may be adding to the growing problem of bacterial resistance. In particular, such trials seem most useful when they focus on patients who are at higher risk of these specific infections—in this case, younger, healthy males.

Finally, as Rao et al. wisely observed, doxycycline is a bacteriostatic agent, which slows the growth and production of bacteria, rather than a bactericidal agent, which kills bacteria.  Given that antimicrobial limitation, doxycycline might not be the most appropriate prophylactic drug to be investigating for these cases.

Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD is a consultant orthopaedic trauma surgeon at Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, and he is a member of the JBJS Social Media Advisory Board.

References

  1. Gausden EB, Villa J, Warner SJ, Redko M, Pearle A, Miller A, Henry M, Lorich DG, Helfet DL, Wellman DS. Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes.  J Orthop Trauma. 2017 Apr;31(4):229-235.
  2. Chuang MJ, Jancosko JJ, Mendoza V, Nottage WM. The Incidence of Propionibacterium acnes in Shoulder Arthroscopy.  2015 Sep;31(9):1702-7.
  3. Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA III. Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. J Bone Joint Surg 2016;98:2047-2051.
  4. Rao AJ, Chalmers PN, Cvetanovich GL, O’Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty.  J Bone Joint Surg Am. 2018 Jun 6;100(11):958-964.
June 12, 2018  

Sarcopenia: An Independent Predictor of Mortality in Geriatric Acetabular Fractures

PLVIOrthoBuzz 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.

Fractures in the elderly are a growing problem in developed countries and generally carry a significant morbidity and mortality burden. When considering treatment strategies and making prognoses in this patient population, our ability to stratify patient frailty may be just as or more important than classifying the fracture. In a recent study in the Journal of Orthopaedic Trauma, Mitchell et al. evaluate the role of sarcopenia, an age-related loss of muscle mass, in predicting 1-year mortality among elderly patients with acetabular fractures.1

The authors performed a retrospective review of nearly 150 patients >60 years of age who sustained an acetabular fracture between 2003 and 2014. The authors used the lowest quartile of the psoas:lumbar vertebral index (PLVI) in the cohort as a surrogate for sarcopenia. The PLVI is calculated by measuring the cross-sectional area of the psoas muscle bellies at the L4 level and dividing that number by the cross-sectional area of the L4 vertebral body measured at the superior endplate (see image). Lower PLVIs represent greater loss of muscle mass.

After controlling for confounding variables, the authors found that sarcopenia was an independent risk factor for 1-year mortality. Specifically, patients with sarcopenia had a 32.4% 1-year mortality rate compared to a rate of 11.0% in patients without sarcopenia. Age and injury severity score (ISS) were also predictive of 1-year mortality, and patients with all 3 factors (age >75 years, ISS >14, and sarcopenia) had a mortality rate of 90%.

This article highlights the importance of risk-stratifying patients in ways that account for more than their presenting injuries. In the elderly population, chronologic age is only one of many indicators of frailty. Sarcopenia may be another marker that we can use to better understand the general well-being of our patients. As Mitchell et al. mention, more research must be done to precisely define a PLVI cutoff for sarcopenia to make this index a clinically useful tool. Ultimately, doing so will allow us to offer elderly patients and their families more thoughtful and evidence-based counseling regarding treatment and prognosis.

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

Reference

  1. Mitchell, Phillip M., et al., Sarcopenia is Predictive of 1-year Mortality After Acetabular Fractures in Elderly Patients.” Journal of Orthopaedic Trauma, June 2018; 32 (6) : 278-282.
June 5, 2018  

Bunion Treatments Abound Amid Multiple Etiologies

Bunionectomy for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS, in response to a recent study in Foot and Ankle Clinics of North America.

It makes sense that orthopaedic conditions with multiple etiologic factors have a corresponding variety of treatment options. So it is with hallux valgus (bunion deformity). In the June 2018 edition of Foot and Ankle Clinics of North America, Smyth and Aiyer1 focus on the pathoanatomy of hallux valgus and various approaches to selecting an operative option.

With more than 100 different operative procedures described to correct hallux valgus, it can be challenging to pick the “right” procedure for each patient. The etiology of hallux valgus includes intrinsic factors (e.g., a long first metatarsal, the shape of the metatarsal head, and soft-tissue imbalances across the hallux metatarsophalangeal [MP] joint) and extrinsic factors (e.g., high-heeled, narrow toe-box shoes). Other kinematic factors of the foot, such as hypermobility of the first ray, are associated with hallux valgus, as is pes planus (flatfoot). Whatever the etiology, hallux valgus almost always progresses in a relatively predictable manner.1

Careful preoperative analysis is required to successfully treat hallux valgus, with the goal of restoring static and dynamic balance around the first MP joint. For optimum outcomes, a soft-tissue procedure (e.g., modified McBride procedure) is now commonly combined with osseous corrective techniques. The chevron osteotomy, which has been modified in multiple ways, achieves acceptable outcomes with reportedly high patient satisfaction levels, as does a percutaneous distal metatarsal osteotomy.2

More severe deformities are usually treated with proximal first metatarsal osteotomies—such as  a proximal chevron, Ludloff osteotomy, or Scarf osteotomy—to increase the possible angular correction of the metatarsal. While these procedures are more “powerful” correction options, some studies have shown recurrence rates up to 30% at 10 years of follow up.1,2 In cases of severe deformity accompanied by arthritis of the tarsometatarsal (TM) joint, a modified Lapidus procedure may be an option for stabilizing the first TM joint. Hallux MP arthrodesis is also considered in patients who have severe deformity, arthritis, and neuromuscular disorders, and for the revision of a previously failed hallux valgus surgery.

There is currently no consensus as to which procedure is the gold standard for treating hallux valgus. Despite multiple comparative studies assessing the outcomes of different techniques, the decision ultimately depends on surgeon and patient preferences.

Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh and a member of the JBJS Social Media Advisory Board.

References

  1. Smyth NA & Aiyer AA 2018, ‘Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?’, Foot and Ankle Clinics, 23, no.2, pp.171-182.
  2. Adams SB, 2017, JBJS Clinical Summary: Hallux Valgus (Bunion Deformity), viewed 27 may 2018, https://jbjs.org/summary.php?id=188

Related Articles from JBJS Essential Surgical Techniques

May 11, 2018  

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.
May 9, 2018  

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
May 4, 2018  

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.

March 14, 2018  

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.

June 21, 2017  

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.

June 6, 2017  

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.

April 6, 2017  

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.
« Older Posts
Newer Posts »