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What’s New in Hip Replacement 2018

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Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Mengnai Li, MD, co-author of the September 19, 2018 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 100 studies covered in the Specialty Update.

The Benefits of HXLPE
–A double-blinded study that randomized patients to receive either a conventional polyethylene liner or one made from highly cross-linked polyethylene (HXLPE) found that, after a minimum of 10 years, the HXLPE group had significantly lower wear rates, lower prevalence of osteolysis, and lower revision rates than the conventional-liner group.

Outcomes for Hip Fracture vs OA
–A propensity score-matched cohort analysis of NSQIP data found that total hip arthroplasty (THA) undertaken to treat hip fractures among Medicare beneficiaries was significantly associated with an increased risk of CMS-reportable complications, non-homebound discharge, and readmission, relative to THA undertaken to treat osteoarthritis.1

Infection Risk Factors
–A multicenter retrospective study found that a threshold of 7.7% for hemoglobin A1c was more predictive of periprosthetic joint infection than the commonly used 7%, and the authors suggest that 7.7% should be considered the goal in preoperative patient optimization.2

THA in Patients with RA
–Recently published guidelines from the American College of Rheumatology and AAHKS regarding antirheumatic medication use in patients with rheumatic diseases who are undergoing THA suggest the following:

  • Continuing nonbiologic disease-modifying antirheumatic drugs (DMARDs)
  • Continuing the same daily dose of corticosteroids
  • Withholding biologic agents prior to surgery
  • Planning surgery for the end of the biologic dosing cycle.

All recommendations are conditional due to the low or moderate-quality evidence on which they were based.3

Blood Management
–A double-blinded, randomized trial found that oral tranexamic acid (TXA) provided equivalent reductions in blood loss in the setting of primary THA, at greatly reduced cost, compared with intravenous TXA.

References

  1. Qin CD, Helfrich MM, Fitz DW, Hardt KD, Beal MD, Manning DW. The Lawrence D. Dorr Surgical Techniques & Technologies Award: differences in postoperative outcomes between total hip arthroplasty for fracture vs osteoarthritis. J Arthroplasty. 2017 Sep;32(9S):S3-7. Epub 2017 Feb 6.
  2. Tarabichi M, Shohat N, Kheir MM, Adelani M, Brigati D, Kearns SM, Patel P, Clohisy JC, Higuera CA, Levine BR, Schwarzkopf R, Parvizi J, Jiranek WA. Determining the threshold for HbA1c as a predictor for adverse outcomes after total joint arthroplasty: a multicenter, retrospective study. J Arthroplasty. 2017 Sep;32(9S): S263-7: 267.e1. Epub 2017 May 11.
  3. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, Gewurz- Singer O, Giles JT, Johnson B, Lee S, Mandl LA, Mont MA, Sculco P, Sporer S, Stryker L, Turgunbaev M, Brause B, Chen AF, Gililland J, Goodman M, Hurley-Rosenblatt A, Kirou K, Losina E, MacKenzie R, Michaud K, Mikuls T, Russell L, Sah A, Miller AS, Singh JA, Yates A. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2017 Sep;32(9):2628-38. Epub 2017 Jun 16.

Primary TJA Volume Growth from 2014 to 2030: Not So Fast?

TJA Volume for OBuzzAnnual volume projections for total joint arthroplasty (TJA) have been cited frequently and applied broadly, often to estimate future costs. But with a slowdown in the growth of the annual incidence of total knee arthroplasty (TKA), updated projections are needed, and that’s what Sloan et al. provide in the September 5, 2018 issue of JBJS.

Using the National Inpatient Sample to obtain TJA incidence data, the authors first analyzed the volume of primary TJA procedures performed from 2000 to 2014. They then performed regression analyses to project future volumes of TJA procedures. Here are the numbers based on the 2000-to-2014 data:

  • Primary total hip arthroplasty (THA) is projected to grow 71%, to 635,000 annual procedures by 2030.
  • Primary TKA is projected to grow 85%, to 1.26 million annual procedures by 2030.

However, the TKA procedure growth rate has slowed in recent years, and models based on 2008-to-2014 data project growth to only 935,000 annual TKAs by 2030—325,000 fewer procedures relative to the 2000-to-2014 models.

Earlier studies, notably one by Kurtz et al. in 2007, obviously could not account for the reduced growth rate in TKA after 2008. A 2008 analysis by Wilson et al., based on the Kurtz et al. data, estimated that annual Medicare expenditures on TJA procedures would climb  from $5 billion in 2006 to $50 billion in 2030. “Using our projections,” say Sloan et al., “we predict that Medicare expenditures on these procedures in 2030 will be less than half of that predicted by Wilson et al.”

These findings lend credence to the authors’ observation that “it is imperative that projections of orthopaedic procedures be regularly evaluated and updated to reflect current rates.”

Helpful Hint for Managing Femoral Neck Stress Fractures

Hip Effusion for OBuzzThe incidence of patients presenting with proximal thigh and groin pain is increasing along with increased interest in recreational athletic activity. When it is associated with a history of increased physical activity, this pain profile often prompts the ordering of a hip MRI if presenting radiographs are unremarkable. However, surgeons often find it difficult to make accurate prognoses and treatment recommendations when the MRI findings suggest a femoral neck stress fracture.

In the September 5, 2018 issue of The Journal, Steele et al. provide us with helpful hints for determining when to proceed with surgical stabilization of the femoral neck in this clinical scenario. Of the femoral neck stress fracture patients in this study who progressed to a surgical procedure, >85% had an effusion on the initial MRI, compared with only 26% of those whose condition resolved with nonoperative treatment. In statistical terms, those who had a hip effusion had an 8-fold increased risk of progression to surgery compared to those without a hip effusion. Meanwhile, the overall fracture-line percentage on the initial MRI turned out to be a poor metric for predicting progression.

Stabilization of a femoral neck stress fracture with percutaneous implants usually improves pain and predictably prevents displacement of the fracture and the attendant risk of nonunion and osteonecrosis of the femoral head. Further clinical research should help validate the seemingly reliable MRI-based predictor identified by these authors.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Getting to the Core of Bone Marrow Lesions

Bone Marrow Lesion for OBuzzThis post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

The terms “bone marrow edema,” “bone marrow lesion” (BML), and “bone bruise” are often used interchangeably to refer to areas in cancellous bone that have hyperintense marrow signal in fluid-sensitive, fat-suppressed MRI sequences. Although most commonly observed in knee MRIs, BMLs can be seen in a variety of joints. In the hip, they are seen in transient osteoporosis and rapid-onset osteoarthritis. The term “bone bruise” is often specifically applied in the setting of an injury, such as lateral tibial plateau hyperintense changes that are seen after an anterior cruciate ligament rupture.

In the setting of knee osteoarthritis, BMLs are a response to degeneration of menisci, articular cartilage, synovium, or bone itself. One of the mechanisms associated with BMLs seems to be secondary to circulatory response and bone turnover. In one study covered in a 2017 review article1, patients with OA and associated BMLs were randomized to receive the bone antiresorptive agent zoledronic acid (ZA) or placebo. At 6 months, VAS pain scores in the ZA group were reduced by ZA, the reduction in BML area was greater in the ZA group than in the placebo group, and a greater proportion in the ZA group achieved a clinically significant reduction in BML size (39% vs. 18%, p <0.044). A larger study is planned to further define the relationship between reduction in BML size and pain scores.

Regarding “crosstalk” between subchondral bone and articular cartilage in joint disease, recent data suggest that numerous canals and porosities connect the bone to cartilage at the interface. Treatment of the bone compartment with antiresorptives and anti-TGF-β at specific early time points has been shown to have chondroprotective effects in animal models. Additionally, one study identified s14-3-3ε, a short extracellular protein, as a mediator critical in the communication between subchondral bone and cartilage in OA. This may prove to be a potential target for therapeutic or prognostic use.

Numerous articles have outlined the abundance of trabecular microfractures seen in areas where BMLs are present. A commonly held hypothesis is that resorption cavities caused by bone remodeling can act as stress concentrations, promoting further microdamage and leading to a cycle of damage-remodeling-damage. Some individuals may be more prone to rapid bone turnover and thus more prone to developing bone edema.

When your clinical attention is directed to BMLs, their shape and extent may influence nonsurgical treatment decisions. Conservative management may be directed by a better understanding of how BMLs contribute to pain and OA progression.

Reference

  1. Alliston T, Hernandez CJ, Findlay DM, Felson DT, Kennedy OD. Bone marrow lesions in osteoarthritis: What lies beneath. J Orthop Res. 2017 Dec 21. doi: 10.1002/jor.23844. [Epub ahead of print] PMID: 29266428

Structural Allografts Can Work for Acetabular Defects in THA

Structural Allograft for OBuzzAllograft bone is used often in orthopaedic surgery. However, the use of structural allografts to address large acetabular defects in total hip arthroplasty (THA) is not common. But it may become more so in light of the study by Butscheidt et al. in the August 15, 2018 issue of JBJS. The authors add to our knowledge about these relatively rare procedures by evaluating the incorporation of structural acetabular allografts into host bone among 13 complete pelvic explants containing allograft that had been in place for a mean of 13 years.

Using sophisticated imaging and histological techniques, the authors found that in 10 out of the 13 specimens retrieved, 100% of the interface was characterized by direct contact and additional overlap of the allograft bone and the host bone. The remaining 3 allografts showed direct contact along 25% to 80% of the interface.  The authors found no correlation between ingrowth of the host bone into the allograft and the amount of time the allograft had spent in situ, leading them to surmise that “a large proportion of the incorporation process may be completed within the first weeks.”

Large, structural allografts are not commonly used for acetabular reconstructions, as most surgeons seem to favor other options.  (See the JBJS Clinical Summary on “Managing Acetabular Defects in Hip Arthroplasty.”) While a postmortem study of 13 cases may not be “practice-changing,“ the Butscheidt et al. analysis does provide some detailed clarity as to what surgeons can expect from these large allograft reconstructions in terms of incorporation with host bone. Obviously, one limitation of this study is that structural allografts that never incorporated with the host bone probably failed early and would not be available for analysis in a long-follow-up retrieval study.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS 100: Harris Hip Score, Clavicle Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures—Treatment by Mold Arthroplasty: An End-Result Study Using a New Method of Result Evaluation
W H Harris: JBJS, 1969 June; 51 (4): 737
The most lasting legacy from this classic 1969 article from William Harris is the author’s proposed hip score. A “single, reliable figure” designed to be equally applicable to different hip problems and different treatments, the Harris Hip Score is still used worldwide today in routine evaluations before and after hip arthroplasty. Not surprisingly, this article remains the most frequently cited paper in the hip arthroplasty literature.

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures
Canadian Orthopaedic Trauma Society: JBJS, 2007 January; 89 (1): 1
Amid the ongoing debate about whether to operate on which type of clavicle fractures, this multicenter, randomized clinical trial stands out for its rigorous design and focus on patient-oriented outcomes. Local irritation and unsightly prominence from hardware notwithstanding, these findings support primary plate fixation of completely displaced midshaft clavicle fractures in active adult patients.

Cross-Linked Polyethylene for Total Hip Arthroplasty Markedly Reduces Revision Surgery at 16 Years

Total hip arthroplasty (THA) is an effective operation for the management of end-stage hip osteoarthritis, but long-term success can be limited by wear of the polyethylene bearing surface.

Full article: https://bit.ly/2nlQxoL

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More Evidence of Patient Benefits with Cross-Linked Polyethylene

XLPE Cup for OBuzzIn an OrthoBuzz post last year titled “Has Conventional Polyethylene Become Obsolete?,” we featured results from a small randomized trial that documented much-improved implant survival over 10 years with acetabular components made from cross-linked polyethylene (XLPE) compared with conventional polyethylene (CPE). In the August 1, 2018 issue of The Journal, we find further corroboration of the benefits realized by patients who receive XLPE acetabular components.

deSteiger et al. analyzed registry data involving more than 240,000 total hip arthroplasty (THA) patients and found markedly lower revision rates in those who received XPLE rather than CPE acetabular components. At a mean follow-up of 16 years, the cumulative percentage of revisions was 6.2% in the  XPLE group versus 11.7% in the CPE group.  Among patients <55 years of age at the time of THA, at 7 years there was a five-fold increase in revision rates for procedures done with CPE compared to those done with XLPE.

Because the authors observed that the between-group differences in revision rates became more pronounced over time, it is possible that this difference will continue to grow as more data is gathered. When we consider the vast number of THAs performed around the world each year, this XLPE-related decrease in revision rate could have a beneficial impact on millions of patients.

The documented success so far of XPLE is a clear case where understanding the nature of the original problem (polyethylene wear) and applying consistent and innovative research to find a solution have allowed patients worldwide to reap the benefits associated with THA, with some assurance that their hip replacement may, in fact, last for their rest of their life.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Preop Opioid Use Associated with Higher Readmission and Revision Rates after TJA

Prescription opioid use is epidemic in the U.S. Recently, an association was demonstrated between preoperative opioid use and increased health-care utilization following abdominal surgeries. #JBJSInfographics #visualabstract #JBJS

Full article: https://bit.ly/2uVhwfl

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Prescribing Opioids: Smallest Dose for Shortest Time

Opioid for OBuzzSome people are tired of reading and hearing about the opioid crisis in America. When this topic comes up at meetings, there are rumblings in the crowd. When it’s brought up during hospital safety briefings, there are not-so-subtle eye-rolls, and occasionally I hear frank assertions of “enough already” when new information on the topic appears in the literature. Yet, as two studies in the July 18, 2018 edition of JBJS highlight, this topic is not going away any time soon. And for good reason. We are only starting to scratch the surface of the serious unintended consequences—beyond the risk of addiction—from overly aggressive prescribing and consumption of narcotics.

The first article, by Zhu et al., directly addresses the topic of overprescribing by doctors in China. The authors evaluated how many opioid pills were given to patients who sustained fractures that were treated nonoperatively. The mean number of opioid pills patients reported consuming (7.2) was less than half the mean number prescribed (14.7). More than 70% of patients did not consume all the opioid pills they were prescribed, and 10% of patients consumed no opioids at all. Zhu et al. conclude that “if opioids are used [in this setting], surgeons should prescribe the smallest dose for the shortest time after considering the injury location and type of fracture or dislocation.”

The second article, by Weick et al., underscores the patient-outcome and societal impact of opioid use prior to total hip and knee arthroplasty. Patients from North America who consumed opioids for 60+ days prior to their joint replacement had a significantly increased risk of revision at both the 1-year and 3-year postoperative follow-ups, compared to similar patients who were opioid-naïve before surgery. Similarly, patients who used opioids for 60+ days prior to undergoing a total hip or knee arthroplasty had a significantly increased risk of 30-day readmission, compared to patients who were opioid-naïve.  All these differences held when the authors made adjustments for patient age, sex, and comorbidities—meaning that tens of thousands of patients each year can expect to have worse outcomes (and add a large cost burden to the health care system) simply by being on opioid medications for two months preoperatively.

These articles address two very different research questions in two very different regions of the world,  but they help expose the chasm in our knowledge surrounding opioid use and misuse. We have been prescribing patients more narcotics than they need while just starting to recognize the importance of minimizing opioid use preoperatively in an effort to maximize surgical outcomes. These two competing impulses emphasize why further opioid-related studies are important.  While continuing to look at the negative effects these medications can have on patients, we have to take a hard look at our contribution to the problem.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media