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May 2018 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of May 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Quality of Life in Symptomatic Individuals After Anterior Cruciate Ligament Reconstruction, With and Without Radiographic Knee Osteoarthritis.”

The authors conclude that diagnosing radiographic osteoarthritis in symptomatic individuals after ACL reconstruction may be valuable, because targeted strategies to facilitate participation in satisfying activities have the potential to improve quality of life in these patients.

What’s New in Sports Medicine 2018

Anatomy of male knee pain in blueEvery 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, OrthoBuzz asked Albert Gee, MD, a co-author of the April 18, 2018 Specialty Update on Sports Medicine, to select the five most clinically compelling findings from among the 30 studies cited in the article.

Anterior Cruciate Ligament (ACL) Reconstruction
–The conversations about graft selection for ACL reconstruction go on. A meta-analysis of 19 Level-I studies comparing 4-strand hamstring autograft with patellar tendon grafts1 revealed no differences in terms of rupture rate, clinical outcome scores, or arthrometer side-to-side testing at >58 months of follow-up. The prevalence of anterior knee pain and kneeling pain was significantly less in the hamstring group, and that group also exhibited a lower rate of extension deficit.

Cartilage Repair
–Fourteen-year outcomes from a randomized controlled trial (n = 80 patients) comparing autologous chondrocyte implantation (ACI) with microfracture for treating large focal cartilage defects included the following:

  • No significant between-group difference in functional outcome scores
  • Fairly high treatment failure rates in both groups (42.5% in the ACI group; 32.5% in the microfracture group)
  • Radiographic evidence of grade 2 or higher osteoarthritis in about half of all patients

These findings raise doubts about the long-term efficacy of these two treatments.

Rehab after Rotator Cuff Repair
–A randomized trial comparing early and delayed initiation of range of motion after arthroscopic single-tendon rotator cuff repair in 73 patients2 found no major differences in clinical outcome, pain, range of motion, use of narcotics, or radiographic evidence of retear. The early motion group showed a small but significant decrease in disability. The findings indicate that early motion after this surgical procedure may do no harm.

Platelet-Rich Plasma (PRP)
–A systematic review of 105 human clinical trials that examined the use of PRP in musculoskeletal conditions revealed the following:

  • Only 10% of the studies clearly explained the PRP-preparation protocol.
  • Only 16% of the studies provided quantitative information about the compositi0on of the final PRP product.
  • Twenty-four different PRP processing systems were used across the studies.
  • Platelet composition in the PRP preparations ranged from 38 to 1,540 X 103/µL.

Consequently, care should be taken when drawing conclusions from such studies.

Meniscal Tear Treatment
–A follow-up to the MeTeOR trial (350 patients initially randomized to receive either a partial arthroscopic meniscectomy or physical therapy [PT]) found that crossover from the PT group to the partial meniscectomy group was significantly associated with higher baseline pain scores or more acute symptoms within 5 months of enrollment. Investigators also found identical 6-month WOMAC and KOOS scores between those who crossed over and those who had surgery initially. These findings suggest that an initial course of PT prior to meniscectomy does not compromise outcomes.

References

  1. Chee MY, Chen Y, Pearce CJ, Murphy DP, Krishna L, Hui JH, Wang WE, Tai BC,Salunke AA, Chen X, Chua ZK, Satkunanantham K. Outcome of patellar tendon versus 4-strand hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized trials. Arthroscopy. 2017 Feb;33(2):450-63. Epub 2016 Dec 28.
  2. Mazzocca AD, Arciero RA, Shea KP, Apostolakos JM, Solovyova O, Gomlinski G, Wojcik KE, Tafuto V, Stock H, Cote MP. The effect of early range of motion on quality of life, clinical outcome, and repair integrity after arthroscopic rotator cuff repair. Athroscopy. 2017 Jun;33(6):1138-48. Epub 2017 Jan 19.

Risk Reduction Compared with Access to Care: The Trade-Off of Enforcing a BMI Eligibility Criterion for Joint Replacement

Morbidly obese patients with severe osteoarthritis benefit from successful total joint arthroplasty. However, morbid obesity increases the risk of complications. https://bit.ly/2qpfj8w #JBJS

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Effect of Postoperative Mechanical Axis Alignment on Survival and Functional Outcomes of Modern Total Knee Arthroplasties with Cement

Abdel et al. report on the 20-year survivorship of total knee arthroplasty implants that were mechanically aligned (0° ± 3° relative to the mechanical axis) compared with those that were outside that range and considered outliers. https://bit.ly/2uqY77S #JBJS

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JBJS 100: Autologous Chondrocyte Implantation and Hip 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 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:

Autologous Chondrocyte Implantation Compared with Microfracture in the Knee: A Randomized Trial
G Knutsen, L Engebretsen. T C Ludvigsen, J O Drogset, T Grøntvedt, E Solheim, T Strand, S Roberts, V Isaksen, and O Johansen: JBJS, 2004 March; 86 (3): 455
In the first published randomized trial to compare these 2 methods for treating full-thickness cartilage defects, both procedures demonstrated similar clinical results at 2 years of follow-up. The authors also performed arthroscopic and histologic evaluations at 2 years and again found no significant differences between the groups. Since 2004, however, longer-term follow-ups have suggested that autologous chondrocyte implantation is more durable than microfracture (see Clinical Summary on Knee Cartilage Injuries).

The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip 
M R Baumgaertner, S L Curtin, D M Lindskog, and J M Keggi: JBJS, 1995 July; 77 (7): 1058
So-called “cutout” of the lag screw in sliding hip screw fixation of peritrochanteric hip fractures was a recognized cause of failure long before this landmark JBJS study was published in 1995. Twenty-three years later, when value consciousness has repopularized this reliable fixation method (especially in stable fracture patterns), the tip-apex distance as a strong predictor of cutout remains an important surgical consideration.

JBJS EST 2017 Editor’s Choice Awards

JBJS Essential Surgical Techniques (EST) is pleased to congratulate the winners of its two Editor’s Choice Awards for 2017:

The award for best surgical-technique article went to Morteza Kalhor, MD; Diego Collado, MD; Michael Leunig, MD; Paulo Rego, MD; and Reinhold Ganz, MD for Recommendations to Reduce Risk of Nerve Injury During Bernese Periacetabular Osteotomy (PAO).

EST Winner 1 for OBuzz

The recipients of the best Key Procedures video award were Jorge Chahla, MD; Gilbert Moatshe, MD; Lars Engebretsen, MD, PhD; and Robert F. LaPrade, MD, PhD for Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction.

EST Winner 2 for OBuzz

Click here to learn more about the annual EST Editor’s Choice competition.

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.

Joint Laxity Is a Risk Factor for Poor Outcomes After ACL Reconstruction

The purposes of this investigation were to compare outcomes of anterior cruciate ligament (ACL) reconstruction between patients with generalized joint laxity and those without it and to investigate the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively. #JBJSVideoSummaries #JBJSmedia

Full article: http://bit.ly/2F6dlUY

Spinal Cord Compression/Joint Laxity & ACL

Spinal cord injury in the cervical spine is commonly accompanied by cord compression and urgent surgical decompression may improve neurological recovery. http://bit.ly/2FbYWpA #JBJSInfographics #JBJSJBJS.IG.16.00995.ig

Is there a difference in outcomes of ACL reconstruction between patients with generalized joint laxity and those without it? What are the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively? http://bit.ly/2F6dlUY #JBJS #JBJSInfographics

Joint Laxity InfoGraphic for OBuzz

Generalized Joint Laxity—A Risk Factor for Poor Outcomes After ACL Reconstruction

Joint Laxity InfoGraphic for OBuzzSometimes, being too flexible is not a good thing. In the February 21, 2018 edition of The Journal of Bone & Joint Surgery, Kim et al. show that patients with generalized joint laxity—those who can hyperextend their knees and elbows beyond 10°, for example—tend to have poorer knee-stability and functional outcomes after anterior cruciate ligament (ACL) reconstruction than those who have normal joint flexibility.

The authors studied 8-year outcomes among 163 patients who underwent a unilateral ACL reconstruction. In all cases, the same surgeon performed the same procedure (bone-patellar tendon-bone autograft), and all patients went through the same rehab program.

In terms of graft-rupture rates and contralateral ACL rupture rates over the study period, the authors found no statistically significant differences between the 122 patients without laxity and the 41 patients who were determined preoperatively to have generalized joint laxity. However, at the 8-year follow-up, the patients with laxity had less knee stability (as measured with Lachman and pivot-shift tests and an arthrometer) and worse knee function (as measured with the Lysholm and IKDC scales) than patients without laxity.

Taken together, these findings lead Kim et al. to conclude that “generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction.” We also noted that JBJS Deputy Editor Robert Marx, MD (@drrmarx) remarked on Twitter that “adding lateral ITB [iliotibial band] tenodesis may be helpful for more severe cases with significant knee hyperextension.”

Click here for a two-minute video summary of this study.