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Long-Term Opioid Use Before TKA Raises Risk of Revision

Opioid and TKA Revision.gifGiven the prevalence of opioid prescriptions, many patients present for total knee arthroplasty (TKA) having been on long-term opioid therapy. In the January 4, 2017 edition of The Journal of Bone & Joint Surgery, Ben-Ari et al. determined that patients taking opiate medications for more than three months prior to their TKA were significantly more likely than non-users of opioids to undergo revision surgery within a year after the index procedure.

Among the more than 32,000 TKA patients from Veterans Affairs (VA) databases included in the study, nearly 40% were long-term opioid users prior to surgery. Despite that high percentage, the authors found that chronic kidney disease was the leading risk factor for knee revision among the relevant variables they examined. And even though the authors used a sophisticated natural language/machine-learning tool to analyze postoperative notes, they found no association between long-term opioid use and the etiology of the revisions.

In a commentary accompanying the study, Michael Reich, MD and Richard Walker, MD, note that the study’s very specific VA demographic (94% male) may hamper the generalizability of the findings, especially because most TKAs are currently performed in women. Nevertheless, the commentators conclude that:

  • “The study illuminates the value in limiting opioid use during the nonoperative treatment of patients with knee arthritis.”
  • “Patients who are taking opioids when they present for TKA could reasonably be encouraged to decrease opioid use during preoperative preparation.”
  • “Preoperative use of opioids should be considered among modifiable risk factors and comorbidities when deciding whether to perform TKA.”

Guest Post: New AUC for Surgical Management of Knee OA

knee-spotlight-image.pngOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.

The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.

The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”

Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.

This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence.  This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.

Pre-operative

Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.

Moderate evidence: Diabetic patients have a higher risk of complications after TKA.

Moderate evidence: An 8-month delay to TKA does not worsen outcomes.

Peri-operative

Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.

Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.

Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.

Strong evidence:  The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.

Strong evidence: Drains do not help reduce complications or improve outcomes.

Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.

Strong evidence: All-polyethylene and modular components yield similar outcomes.

Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.

Strong evidence: There is no difference in pain/function with patellar resurfacing.

Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.

Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).

Moderate evidence favors TKA over UKA to avoid future revisions.

Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.

Postoperative

Strong evidence:  Rehab/PT started on day of surgery reduces length of stay.

Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.

Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.

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

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

New Knee Content from JBJS

knee-spotlight-image.pngThe recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.

Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of January 2017:

  • Differences in Short-Term Complications Between Unicompartmental and Total Knee Arthroplasty:
    A Propensity Score Matched Analysis

  • Extensor Mechanism Allograft Reconstruction for Extensor Mechanism Failure Following Total Knee Arthroplasty

  • What’s New in Adult Reconstructive Knee Surgery

  • Bicruciate Substituting Design Does Not Improve Maximal Flexion in Total Knee Arthroplasty: A Randomized Controlled Trial

  • Total Knee Arthroplasty After Previous Knee Surgery: Expected Interval and the Effect on Patient Age

Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.

Visit the JBJS Knee Spotlight website today.

JBJS Reviews Editor’s Choice–Outpatient Joint Replacement?

knee-spotlight-image.png“Necessity is the mother of invention.” In recent years, the demand for total hip, total knee, and unicompartmental knee arthroplasty has grown substantially. However, with limited resources and health-care budgets, there is a need to reduce hospital costs. To that end, a number of surgeons have begun to perform these procedures on an outpatient basis.

Indeed, as the demand for joint replacements grows, it will be imperative to improve patient safety and satisfaction while minimizing costs and optimizing the use of health-care resources. In order to accomplish this goal, surgical teams, nursing staff, and physiotherapists will need to work together to discharge patients from the hospital as soon as safely possible, including on the same day as the operation. The development of accelerated clinical pathways featuring a multidisciplinary approach and involving a range of health-care professionals will result in extensive preoperative patient education, early mobilization, and intensive physical therapy.

In the December 2016 issue of JBJS Reviews, Pollock et al. report on a systematic review that was performed to determine the safety and feasibility of outpatient total hip, total knee, and unicompartmental knee arthroplasty. The authors hypothesized that outpatient arthroplasty would be safe and feasible and that there would be similar complication rates, similar readmission and revision rates, similar clinical outcomes, and decreased costs in comparison with the findings associated with the inpatient procedure. The investigators demonstrated that, in selective patients, outpatient total hip, total knee, and unicompartmental knee arthroplasty can be performed safely and effectively.

A major caveat of this well-conducted study, however, is that, like any systematic review, its overall quality is based on the quality of the individual studies that make up the analysis. In this case, the studies included those that lacked sufficient internal validity, sample size, methodological consistency, and standardization of protocols and outcomes. Thus, going forward, there is a need for more rigorous and adequately powered randomized trials to definitively establish the safety, efficacy, and feasibility of outpatient hip and knee arthroplasty.

Thomas A. Einhorn, MD
Editor, JBJS Reviews

JBJS Classics: Arthroscopy’s Revolutionary Role in Diagnosing Knee Injuries

JBJS Classics Logo.pngOrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Prior to the advent and subsequently ubiquitous use of MRI that most young surgeons are now accustomed to, it was difficult to determine the incidence of several common sports-related injuriesFrank Noyes’ 1980 classic JBJS manuscript, “Arthroscopy in Acute Traumatic Hemarthrosis of the Knee,” was one of the first articles to establish the clear relationship between hemarthrosis and significant intra-articular knee pathology. While the importance of the anterior cruciate ligament (ACL) had just come to light, Noyes’ landmark findings demonstrated the high incidence of ACL injury in association with acute traumatic hemarthrosis (ATH). Furthermore, he delineated arthroscopy’s critical role in accurately diagnosing other associated knee injuries.

This classic manuscript advocated for the use of arthroscopy as a diagnostic tool for the evaluation of ATH at a time when the consequences of a “knee sprain” with acute swelling were unclear.  In patients who did not have obvious laxity, an existing acute rupture of the ACL was often left undiagnosed during initial clinical evaluations. Noyes’ innovation pushed the field to couple clinical examination with arthroscopy in cases of acute knee injuries, to allow for more accurate diagnosis. Following this paper’s publication, and well into the 1980s, research continued to confirm Noyes’ findings that one of the best uses of arthroscopy was for diagnosis of acute knee injuries.

This paper and another Noyes study[1] were among the first to identify the high rate of serious knee injuries among patients with ATH. Noyes’ JBJS paper showed that 72% of knees with ATH were characterized by some degree of ACL injury. Moreover, in knees with complete ACL disruption, both the anterior drawer and flexion-rotation drawer tests proved to be more accurate diagnostically when performed with the patient under anesthesia than when the tests were performed in the clinic. Further, he also established that ACL tear, meniscus tear, and/or cartilage injury must be included in the differential diagnosis of an ATH.

Noyes’ group revolutionized the course of treatment and care for patients with ATH. While we generally no longer use knee arthroscopy as a diagnostic tool, because of this article, we routinely order MRI in the setting of ATH. Noyes’ piece remains timeless and well-deserving of the title of a “JBJS Classic.”

Robert G. Marx, MD, MSc, FRCSC
JBJS Deputy Editor

Naaman Mehta, BS

Stephen Thompson, MD, MEd, FRCSC
JBJS Deputy Editor

Reference

[1] Noyes FR, Paulos L, Mooar LA, Signer B. Knee Sprains and Acute Knee Hemarthrosis: Misdiagnosis of Anterior Cruciate Ligament Tears. Phys Ther. 60(12): 1596-1601, 1980.

No Surprise: Infection Biggest Culprit in Amputation for Failed TKA

Cumulative Amputations_12_7_16.gifOf the hundreds of thousands of total knee arthroplasties (TKAs) performed annually around the world, very few result in failure so irreparable that transfemoral amputation is the last resort. But what does “very few” really mean? In the December 7, 2016 issue of The Journal of Bone & Joint Surgery, Gottfriedsen et al. determine the cumulative incidence of amputation for failed TKAs among nearly 93,000 registered knee replacements performed in Denmark from 1997 to 2013.

The authors used a competing-risk model (which took into account the competing risk of death) to avoid overestimating incidence. From a total of 115 amputations performed for causes related to failed TKA, they calculated a cumulative 15-year incidence of amputation of 0.32%. They noted a tendency toward decreasing incidence during the 2008-2013 period, relative to the 1997-2002 period.

The three most common causes of post-TKA amputation were periprosthetic infection (83%), soft-tissue deficiency (23%), and severe bone loss (18%). The authors add, however, that the latter two causes are “most likely the result of long-term infection together with several revision procedures, in which soft tissue and bone stock are gradually damaged.”

The authors encourage orthopaedists to consider newer treatment options to avoid amputation (such as skin grafts and muscle flaps for soft-tissue loss), but they also assert that, in each individual case, those contemporary approaches should be balanced against the “psychological and physical strains related to repeated surgery performed in an attempt to salvage the knee.”

A Close Look at Crossovers in Knee RCTs

partial_meniscectomyIn a November 16, 2016 JBJS study whose findings have implications for both research and practice, Katz et al. analyzed data from the MeTeOR trial to answer two questions:

  • What prompts patients with meniscal tears and knee osteoarthritis who are randomized to physical therapy (PT) in trials comparing PT to arthroscopic partial meniscectomy (APM) to cross over from nonoperative therapy to APM?
  • Do those who cross over to APM receive symptom relief that’s comparable to those originally randomized to APM?

After careful multivariate analysis of 48 patients who crossed over in the MeTeOR trial (representing 27% of those originally randomized to PT), the authors identified two factors associated with a higher likelihood of crossover: a baseline WOMAC Pain Score of ≥40 and symptom duration of <1 year.  The authors also found that patients who crossed over to APM were just as likely to experience improvement in pain scores as those originally randomized to APM.

From a research standpoint, the authors suggest that future investigators may wish to make “special efforts” to keep patients who present with severe pain and relatively short symptom duration in nonoperative therapy. Clinically, Katz et al. say the findings “underscore the emerging treatment recommendation…to try a PT regimen before opting for APM.”

Updated Knee Content from JBJS

knee-spotlight-image.pngThe recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.

Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of December 2016:

  • Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection to the Knee Following Partial Medial Meniscectomy

  • Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age

  • Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee

  • Weight-Bearing Compared with Non-Weight-Bearing Following Osteochondral Autograft Transfer for Small Defects in Weight-Bearing Areas in the Femoral Articular Cartilage of the Knee

  • Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques

Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.

Visit the JBJS Knee Spotlight website today.

JBJS Webinar: Managing Knee-Arthritis Pain Before and After Surgery

December Webinar Image.jpg

Early on, patients with knee osteoarthritis (OA) often get sufficient pain relief with nonsteroidal anti-inflammatory drugs. But as the condition progresses, many opt for knee replacement. Although knee replacement shows remarkable long-term results, immediate postsurgical pain management is a crucial consideration for orthopaedists and patients.

On Tuesday, December 13, 2016 at 12:30 PM EST, The Journal of Bone & Joint Surgery (JBJS) and PAIN, the official journal of the International Association for the Study of Pain, will host a complimentary webinar focused on relieving pain before and after surgery for knee arthritis.

  • Sachiyuki Tsukada, MD, coauthor of a study in JBJS, will compare pain relief and side effects from intraoperative periarticular injections versus postoperative epidural analgesia after unilateral knee replacement.
  •  PAIN author Lars Arendt-Nielsen, Dr.Med.Sci, will delve into findings from a study examining biomarker and clinical outcomes associated with the COX-2 inhibitor etoricoxib in patients with knee OA.

Moderated by JBJS Associate Editor Nitin Jain, MD, the webinar will include an additional perspective from musculoskeletal pain-management expert Michael Taunton, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all three panelists.

Seats are limited, so register now!

JBJS Reviews Editor’s Choice–Treating ACL Injuries

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

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

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

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

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

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

Thomas A. Einhorn, MD
Editor, JBJS Reviews

Reference

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