Archive | Need to Know RSS for this section

Appropriate Use Criteria for Carpal Tunnel Syndrome

Benson Headshot.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.

Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.

It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.

The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”

However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.

For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.

But perhaps the most compelling question is — why do we need an AUC app in the first place?  Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories?  And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.

However, there is another, critically important theme to the AUC story.  Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide.  As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.”  If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.

With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome.  More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.

Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.

Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.

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: Single-Stage Revision for Failed Shoulder Arthroplasty Is Effective

TSA Infection.gifOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD.

Shoulder arthroplasty continues to grow in popularity, and as the number of shoulder arthroplasties rises, so will the number of revisions. Infection is one major reason for shoulder arthroplasty failure, and Propionibacterium has been increasingly recognized as a major culprit.

However, Propionibacterium infection is difficult to diagnose. Despite improved detection techniques, diagnosis at the time of revision remains elusive because obvious signs of acute infection are often absent. The need to perform explantation in the setting of clinically apparent periprosthetic infection is obvious, but the appropriateness of single-stage revision with antibiotic treatment in shoulders with only apparent mechanical failures remains questionable.

Hsu et al. attempted to address this question in a study published in the December 21, 2016 issue of JBJS. The group retrospectively reviewed the outcomes of 55 shoulders that underwent revision arthroplasty due to continued pain, stiffness, or component loosening without obvious clinical infection. Mean follow up was 48 months. At least five cultures were obtained intraoperatively during each revision, and each case was treated with antibiotics as if were truly infected until the final culture results were received after three weeks. Shoulders were revised to either hemi-arthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty.

Hsu et al. analyzed outcomes according to two groups: the positive cohort (n=27), where shoulders had ≥ 2 cultures positive for Propionibacterium, and the control cohort (n=28), where shoulders had either 0 or 1 positive culture. The two groups were compared by before- and after-revision performance on the simple shoulder test (SST) and pain outcome scores.

Both groups improved postoperatively based on these patient-reported outcome measures, and no significant difference was found between the two groups. Three patients in each group required a return to the OR. Gastrointestinal side effects were the most commonly reported complication from prolonged antibiotic administration.

This study design was limited by its retrospective nature and the lack of a two-stage revision treatment comparison group. Furthermore, this study included only patients with no signs of clinical infection, and the findings may not be applicable to patients with perioperative signs of infection. The study also incorporated three revision surgery implant options, which could have influenced postoperative SST and pain scores. Larger, multicenter controlled trials will be needed to produce a more definitive answer to this complicated question.

Still, there are clear benefits of single-stage revision over two-stage revision, especially with regard to operative time, anesthesia risks, and patient recovery. Given the wide antibiotic sensitivity profile of Propionibacterium and these initial results from Hsu et al., single-stage revision with appropriate antibiotic therapy may be suitable for patients undergoing revision shoulder arthroplasty in the setting of suspected Propionibacterium infection.

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

Guest Post: Own the Bone Improves Osteoporosis Care

ownbone_logo-r.pngOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD.

In the December 21, 2016 edition of the Journal of Bone & Joint Surgery, Bunta, et al. published an analysis of data from the Own the Bone quality improvement program collected between January 1, 2010 and March 31, 2015. Over this period of time, 125 sites prospectively collected detailed osteoporosis and bone health-related data points on men and women over the age of 50 who presented with a fragility fracture.

The Own the Bone initiative is more than a data registry; it’s a quality improvement program intended to provide a paradigm for increasing the diagnostic and therapeutic recognition (i.e. “response rate”) of the osteoporosis underlying fragility fractures among orthopaedic practices that treat these injuries.  With more than 23,000 individual patients enrolled, and almost 10,000 follow-up records, this is the most robust dataset in existence on the topic.

This initiative has more than doubled the response rate among orthopaedic practices treating fragility fractures. The number of institutions implementing Own the Bone grew from 14 sites in 2005-6 to 177 in 2015. According to Bunta et al., 53% of patients enrolled in the Own the Bone quality Improvement program received bone mineral density testing and/or osteoporosis therapy following their fracture.

Own the Bone was a natural progression of rudimentary efforts that came about during the Bone and Joint Decade, and it marks a strategic effort on the part of the American Orthopedic Association to identify and treat the osteoporosis underlying fragility fractures.  Multiple studies have demonstrated that only 1 out of every 4 to 5 patients who present with a fragility fracture will receive a clinical diagnosis of osteoporosis and/or active treatment to prevent secondary fractures related to osteoporosis. Ample Level-1 evidence demonstrates that the initiation of first-line agents like bisphosphonates, or second-line agents when indicated, can reduce the chance of a subsequent fragility fracture by at least 50%.  We know these medicines work.

We also know that osteoporosis is a progressive phenomenon. Therefore, failing to respond to the osteoporosis underlying fragility fractures means we as a medical system fail to treat the root cause in these patients. The fracture is a symptom of an underlying disease that needs to be addressed or it will continue to produce recurrent fractures and progressive decline in overall health.

The members of the Own the Bone initiative must be commended for their admirable work. We as an orthopedic community need to attempt to incorporate lessons learned through the Own the Bone experience into our practice to ensure that we provide complete care to those with a fragility fracture. The report from Bunta et al. represents a large—but single—step forward on the journey toward universal recognition and treatment of the diminished bone quality underlying fragility fractures. I look forward to additional reports from this group detailing their continued success in raising the bar of understanding and intervention.

Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN.

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.

The Most-Read JBJS Reviews Articles of 2016

11-2016_VCR_II_Template-Final.jpg As an end-of-year thank-you to the orthopaedic community, we’re offering limited-time full-text access to the five most-read JBJS Reviews articles during 2016.

The fact that several of these most-read articles were published prior to 2016 is testament to the durable utility of the orthopaedic information published in JBJS Reviews.

JBJS Case Connections—Osteochondritis Dissecans: Baseball and Genetics

Shoulder_OCD_12_29_16.png The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.

The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:

Among the take-home points emphasized in this Case Connections article:

  • MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
  • Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
  • There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.

The Most-Read JBJS Articles of 2016

11-2016_VCR_II_Template-Final.jpgAs an end-of-year thank-you to the orthopaedic community, we’re offering limited-time full-text access to the five most-read JBJS articles of 2016. The fact that several of these most-read articles were published prior to 2016 is testament to the durable utility of orthopaedic research published in The Journal of Bone & Joint Surgery.

JBJS Webinar–Clubfoot: Predicting and Treating Ponseti Method Failures

jan. webinar speakers.JPG

The Ponseti method is a proven treatment for idiopathic clubfoot, yielding excellent outcomes with minimal pain or disability. However, as many as 40% of patients fail to respond to initial treatment or develop recurrent deformities.

On Wednesday, January 25, 2017 at 8:00 PM EST, The Journal of Bone & Joint Surgery will host a complimentary webinar that delves into two recent JBJS studies investigating how to predict which patients are most likely to get subpar results from the Ponseti method, and how best to manage clubfoot relapses if they occur.

  • Matthew Dobbs, MD, describes in detail various soft-tissue abnormalities present in patients with treatment-resistant clubfoot that are not present in treatment-responsive patients. These parameters could be used to predict which clubfoot patients are at greater risk of relapse.
  • Jose Morcuende, MD, will spotlight findings from a study that followed treated clubfoot patients for 50 years to determine whether relapses managed with repeat casting and tibialis tendon transfer during early childhood prevented future relapses.

This webinar is moderated by James Kasser, MD, surgeon-in-chief at Boston Children’s hospital and a member of the JBJS Board of Trustees. The webinar will offer additional perspectives on the authors’ presentations from two clubfoot-management experts—Steven Frick, MD and Gregory Mencio, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.

Seats are limited, so register now!