German Knee OA Guidelines Mirror Findings in JBJS Reviews Article
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Prof. Joerg Jerosch, in response to a recent article in JBJS Reviews.
I congratulate Vannabouathong et al. for the well-performed and relevant systematic review. In Germany, the Association of Scientific Medical Societies (AWMF) just published a guideline on the medical treatment of knee osteoarthritis (see: https://www.awmf.org/uploads/tx_szleitlinien/033-004l_S2k_Gonarthrose_2018-01_1.pdf), which comes to very similar conclusions as those presented in this systematic review.
The new German guideline suggests a four-stage algorithm starting with topical NSAIDs and escalating to oral NSAIDs (according to individual risks), then followed either by glucosamine, hyaluronic acid (HA), or corticosteroids, and ends finally with opioids. It was very useful that Vannabouathong et al. used the AAOS description for clinical significance, and it was elegant of them to include the effect of intra-articular placebo in their analysis of intra-articular treatments. This review compares treatment-group differences (not within-patient improvements) and considers that the placebo effect in osteoarthritis trials is typically large, particularly in the case of intra-articular injections. Consequently, the measured effect size would underestimate the clinical benefits for patients1, 2. It is valuable that this systematic review calculated the intra-articular placebo versus the oral placebo effect and added the resulting difference of 0.29 standard deviation (SD) units to the respective effect sizes of the intra-articular treatments.
This review concludes that the intra-articular injection of HA has the most concise effect estimate and exceeds the defined threshold of clinical importance of 0.5 SD units. Thus the clinical usefulness of HA is boosted from “possibly clinically important” to “clinically important” according to the AAOS definitions. This review also investigates HA formulations in terms of different molecular weights. It illustrates clearly the effect sizes of high-molecular-weight HA formulations between 1,500 kDa and 6,000 kDa, as well as those above 6,000 kDa.
One point requiring further discussion is that many patients have contraindications to NSAIDs due to comorbidities or comedications. Our new German guideline points out that NSAIDs are contraindicated for elderly patients (>60 years old) and those with existing ulcers, GI bleeding, or infections with H. pylori. Additional contraindicated factors are comedications such as corticosteroids, anticoagulants, or aspirin. In addition, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) reasons that oral NSAIDs have a moderate effect on pain relief, but they are associated with a 3- to 5-fold increase in the risk of upper GI complications, including peptic ulcer perforation, obstruction, and bleeding3.
Another analysis from the Coxib and Traditional NSAID Trialists (CNT) Collaboration shows that 2 to 4 out of 1,000 patients face GI complications after the daily intake of 150 mg of diclofenac. The same applies for 6 to 16 out of 1,000 patients taking 1,000 mg of ibuprofen per day4. An announcement of the Medicines Commission of the German Medical Profession also mentions high relative risks for GI complications associated with NSAIDs. The German guideline recommends intra-articular HA injections especially for individuals at risk for adverse NSAID side effects and for those for whom NSAIDs are not sufficiently effective.
The German guideline also discusses potentially beneficial effects of combining corticosteroids with HA. This should be a topic for a future systematic review.
Prof Joerg Jerosch is a professor of orthopaedic surgery at Johanna-Etienne Hospital in Neuss, Germany.
References
1. Bannuru RR et al., Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis e meta-analysis, Osteoarthritis Cartilage. 2011 Jun;19(6):611-9. doi: 10.1016/j.joca.2010.09.014.
2. Bannuru RR et al., Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis, Ann Intern Med. 2015 Jan 6;162(1):46-54. doi: 10.7326/M14-1231
3. Bruyere O et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting. Semin Arthritis Rheum, 2016. 45(4 Suppl): p. S3-11
4. Bhala N et al., Coxib and traditional NSAID Trialists’ (CNT) Collaboration, Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013; 382(9894): 769-779
JBJS 100: Talar Neck Fractures, Knee Cartilage Repair
Under 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:
Fractures of the Neck of the Talus
L G Hawkins: JBJS, 1970 July; 52 (5): 991
This article, richly illustrated with radiographs, reports on >1-year results from 43 patients treated after sustaining a vertical fracture of the neck of the talus. Hawkins introduced a 3-group classification system based on the initial radiographic appearance of the fracture, and he provided an in-depth discussion of the complication of avascular necrosis.
Autologous Chondrocyte Implantation and Osteochondral Cylinder Transplantation in Cartilage Repair of the Knee Joint
U Horas, D Pelinkovic, G Herr, T Aigner, R Schnettler: JBJS, 2003 February; 85 (2): 185
In the 15 years since this paper appeared in JBJS, nearly 800 articles have been published that have “autologous chondrocyte implantation” (ACI) in their title. This study—replete with histologic, biopsy-specimen, and electron microscopy images—compared 2-year results among 40 patients who had received either ACI or autologous osteochondral transplants for knee cartilage defects. Both treatments decreased symptoms, but the authors concluded that “the improvement provided by the [ACI] lagged behind that provided by the osteochondral cylinder transplantation.” For more current information on these cartilage-repair techniques, see the JBJS Clinical Summary on Knee Cartilage Injuries.
Getting to the Core of Bone Marrow Lesions
This 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
- 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
New Patient-Outcomes Data Hint at Benefits from Computer-Navigated TKA
Like the vast majority of orthopaedic surgeons, I do not use computer navigation for total knee arthroplasties (TKAs). My hospital does not own the equipment, I have not asked for it, and I feel confident in the outcomes for my patients using current conventional techniques. Moreover, we have not had published data suggesting that using computerized navigation actually improves the one thing we care most about: patient outcomes. However, the two-year data presented by Petursson et al. in the August 1, 2018 issue of JBJS may represent a tipping point.
The authors report on 2-year results from a double-blind, prospective randomized trial evaluating outcomes in 167 patients following TKAs performed using conventional techniques or computer-guided navigation. Both patients and observing radiologists/physical therapists were blinded to the technique used.
Among the many patient-reported measures used to compare 2-year outcomes, the authors found that scores for 3 subscales favored the computer-navigation group. Specifically, the symptom and sports-and-recreation subscales of the KOOS and the stiffness subscale of the WOMAC showed significantly greater improvements in the group that underwent computer-navigated TKA. These results led Petursson et al. to conclude that TKAs completed with the assistance of computer navigation provided better pain relief and function at two years postoperatively.
These are important findings, as this is one of the largest randomized, double-blind analyses comparing computer navigation versus conventional TKA. While previous studies had found computer navigation to be useful in terms of obtaining neutral mechanical alignment, data showing improved patient outcomes was either lacking or revealed no clinically important between-group differences. These 2-year data suggest that this is no longer the case. However, it is important to note that the study does not explicitly state whether patients were still blinded to their treatment at the time when the 2-year follow-up data was collected. If they were no longer blinded at that point of follow-up, the results would need to be viewed from a more tempered perspective.
Either way, it is important to note that in this study—as in previous research investigating similar questions—TKAs completed using conventional techniques also yielded large improvements in patient-reported outcomes. Still, because patients and surgeons alike continue to be intrigued by the possibilities that technological advances in arthroplasty may offer, studies like this are vital.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Gait Mechanics After ACL Reconstruction Differ According to Medial Meniscal Treatment
Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both.
Full article: https://bit.ly/2LPna91
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
JBJS 100: Gait Initiation, ACL Replacement
Under 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 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:
The Initiation of Gait
R A Mann, J L Hagy, V White, D Liddell: JBJS, 1979 March; 61 (2): 232
Using electromyography and force-plate data, this study of 10 healthy men and women revealed that the deceptively simple motion of taking the first step from a standing position is initiated by the unbalanced body harnessing complex neural mechanisms, muscular activity, and biomechanical forces. The findings can inform today’s efforts to prevent falls among the elderly.
Replacement of the Anterior Cruciate Ligament using a Patellar Tendon Allograft
S P Arnoczky, R F Warren, M A Ashlock: JBJS, 1986 January; 68 (3): 376
Fresh or deep-frozen? That was the question researchers asked in this study of 25 dogs whose patellar tendons were replaced with one of these two types of allografts. The fresh allografts incited a marked inflammatory and rejection response, while the deep-frozen allografts appeared to be benign and behaved comparably to autogenous patellar tendon grafts. In the 30-plus years since this 1986 study, we have learned a lot about the immunogenicity and biologic character of transplanted allografts, and this important research continues.
Prescribing Opioids: Smallest Dose for Shortest Time
Some 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
Fluctuating Glucose Levels Linked to Post-TJA Problems
At any given time, a patient’s blood-glucose level is easy to measure. Beyond the standard pre/postoperative lab values, there are finger sticks, transdermal meters, and other modalities that make taking a patient’s glucose “snapshot” pretty straightforward. So why don’t we surgeons keep track of it more frequently before and after joint replacement, when, according to the prognostic study by Shohat et al. in the July 5, 2018 issue of JBJS, fluctuating glucose levels can have a critical impact on outcomes?
By retrospectively studying more than 5,000 patients who had undergone either total hip or total knee arthroplasty, the authors found that increased variability of glucose levels (measured by a coefficient of variation) was associated with increased risks of 90-day mortality, surgical-site infection, and periprosthetic joint infection. Specifically, the authors demonstrated that for every 10-percentage-point increase in the glycemic coefficient of variation, the risk of 90-day mortality increased by 26%, and the risk of periprosthetic or surgical-site infection increased by 20%. These are remarkable increases in extremely important outcome measures, and the associations held regardless of the patient’s mean glucose values prior to or after the surgery. In fact, some of the highest levels of glucose variability were found in patients who had well-controlled glucose levels preoperatively. Furthermore, as Charles Cornell, MD points out in a commentary on this study, “Glucose variability appears to affect surgical prognosis more than chronic hyperglycemia.”
These findings were surprising and a bit concerning. I don’t tend to order routine blood-glucose measurements postoperatively on patients who appear to be euglycemic based on preoperative testing. Yet, according to these data, maybe I should. Findings of high glucose variability postoperatively might now prompt me to consult with endocrine or perioperative medicine specialists or at least consider informing patients with fluctuating glucose levels that they may be at increased risk of serious postoperative complications.
Measuring a patient’s blood sugar is neither challenging nor prohibitively expensive. So why don’t we monitor it more closely? Probably because, until now, we have not had a compelling reason to do so with “low-risk” patients. What this study suggests is that our definition of a “low-risk” patient from a glycemic-control standpoint may be misinformed. And while further research needs to be performed to corroborate these findings, that is a pretty scary thought to digest.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Adductor Canal Block Compared with Periarticular Bupivacaine Injection for Total Knee Arthroplasty
In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. #JBJS #JBJSInfoGraphics #visualabsrtact
Full article: https://bit.ly/2zrZvJW
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