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Has Conventional Polyethylene Become Obsolete in THA?

XLPE for OBuzzHighly cross-linked polyethylene (XLPE) has been in clinical use for nearly 15 years. In acetabular components for total hip arthroplasty (THA), XLPE’s superior wear characteristics and lower revision rates, relative to conventional polyethylene (PE), have been demonstrated in numerous studies. Here is one more: a 10-year Level I study in the October 18, 2017 issue of The Journal of Bone & Joint Surgery by Devane et al.

In this double-blinded, randomized trial, authors measured 2-D, 3-D, and volumetric wear (in mm or mm2), along with wear rates (mm/year), presence or absence of osteolysis, and revision rates in 91 patients at specified time intervals, up to a minimum of 10 years. The following results corroborate the general findings from most other studies on this topic:

  • The mean 3-D wear rate among patients with the XLPE acetabular liner was 0.03 mm/yr, versus 0.27 mm/yr among patients with conventional PE.
  • Eight percent of patients in the XLPE group showed radiographic evidence of osteolysis, versus 38% of patients in the PE group.
  • Patients with the conventional PE liner had a significantly higher revision rate (14.6%) than those with the XLPE liner (1.9%).

There were no significant between-group differences in clinical outcome scores, including the Oxford Hip Score and SF-12 physical well-being score.

The authors note that “the longer-term implications of these findings are unclear,” but their calculations indicated that, through 20 years, none of the XLPE liners would wear through, but 6 of the conventional PE liners would require revision due to wear-through.

More Efficient Orthopaedic Education Needed

WI Banner for OBuzz

The October 4, 2017 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Drs. Peter Scoles and Shepard Hurwitz.

The authors suggest that integration of medical school curricula with the first year of postgraduate training is a practical approach to improving efficiency and reducing costs to both doctors in training and the academic medical centers that help train them. In explaining specific ways to change the paradigm for training orthopaedic surgeons, the authors conclude that an integrative approach would accelerate the process for qualified candidates, while lowering costs and ensuring adequate training opportunities for all.

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

With OCA, Don’t Fret About Condyle Matching

OCA for OBuzz

Osteochondral allograft transplantations (OCAs) are becoming a mainstay of treatment for knee-cartilage injuries. To help ensure that the allograft plug is transplanted with <1 mm of step-off from the surrounding recipient cartilage, many surgeons restrict themselves to orthotopic OCAs—matching the graft-recipient condyles in a lateral-to-lateral or medial-to-medial fashion.

However, in the October 4, 2017 issue of The Journal of Bone & Joint Surgery, Wang et al. demonstrated that both orthotopic and non-orthotopic (e.g., lateral condyle-to-medial condyle) OCA resulted in significantly improved outcomes in 77 cases followed for a mean of 4.3 years. The authors found that reoperation rates and pre- and postoperative scores in physical functioning and pain did not differ significantly between the orthotopic (n=50) and non-orthotopic (n=27) groups. These results suggest that condyle-specific matching may not be necessary.

One problem with orthotopic OCA is that 75% of the available allograft is supplied in the form of lateral condyles, while most full-thickness cartilage lesions presenting for treatment occur in the medial condyle. Consequently, surgeon preferences for orthotopic OCA limit the number of available matches and lead to an estimated 13% of available grafts being discarded.

Noting that many factors contribute to successful resurfacing of cartilage defects in the knee, the authors say that “it may be overly simplistic to assume that a conventionally matched orthotopic allograft will ensure a smooth surface contour at the recipient site.” They go on to conclude that “if surgeons forewent condyle-specific matching, more allografts would be readily available, which would shorten wait times, provide fresher grafts with increased chondrocyte viability, and lower procedure costs.”

Webinar—When Great Surgeons Have Challenging Behaviors

Oct Webinar Speakers
Sometimes the most talented, skilled physicians with whom you work are also prone to displaying challenging behaviors. Often, these physicians are not cognizant of how their colleagues perceive them. So how can you—as the supervisor, friend, and/or peer of such clinicians—help ensure that patients continue to benefit from their clinical and surgical gifts without behavioral difficulties diminishing their contributions?

On Thursday, October 26, 2017 at 8:00 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary webinar that will deliver practical and effective methods you can use to help physicians who are clinically outstanding, but behaviorally difficult, start to make remedial changes.

The presentations about how to be helpful to such colleagues will be led by:

  • Gerald Hickson, senior VP for Quality,Safety, and Risk Prevention at Vanderbilt University Medical Center
  • William Hopkinson, professor of orthopaedic surgery at Loyola Medicine
  • George Russell, professor and chair of orthopaedic traumatology at the University of Mississippi Medical Center

Moderated by Dr. Douglas Lundy, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.

Seats are limited, so register now!

New Level-I Data on TKA Blood Conservation

TXAMinimizing perioperative blood loss during total knee arthroplasty (TKA) helps curtail the risks and costs of allogeneic blood transfusions. Currently, the most popular pharmacological approach to blood conservation is the antifibrinolytic agent tranexamic acid (TXA). But in a randomized trial published in the October 4, 2017 edition of The Journal of Bone & Joint Surgery, Boese et al. found that a similar and much less expensive compound, epsilon-aminocaproic acid (EACA), performed almost as effectively and just as safely as TXA in patients undergoing unilateral knee replacement.

Although the 98 patients in the study who received TXA averaged less estimated blood loss than the 96 patients who received EACA, no transfusions were required in either group, and there were no statistically significant or clinically relevant between-group differences in the change in hemoglobin levels. On the safety/complication side, there were no statistically significant between-group differences in any measured parameter, including postoperative serum creatinine levels or renal, bleeding, or thrombotic complications. However, there were 3 pulmonary emboli in the EACA group compared with only 1 in the TXA group. While that was not a statistically significant difference, “an observed difference of this magnitude could limit the usefulness of EACA in TKA,” the authors caution.

This study did not compare the current cost of the two compounds, but back in 2012, when the authors’ institution added antifibrinolytics to their blood management program, TXA cost $43/g, compared with $0.20/g for EACA. The cost differential is striking, even when you consider that TXA is at least 7 times more potent than EACA on a molar basis, so less of the former drug is required.

Boese et al. conclude that “TXA does not have superior blood conservation effects or safety profile compared with EACA in TKA,” but they cite a need for future equivalence, superiority, and noninferiority trials with these drugs.

Faster Relief for Patients with Painful Bone Metastases

MR Guided Ultrasound for OBuzz2A technique that combines magnetic resonance (MR) imaging with high-intensity focused ultrasound hyperthermia provides faster pain relief than conventional radiation therapy (RT) for patients with a painful bone metastasis.

In the September 20, 2017 issue of JBJS, Lee et al. report on a matched-pair study of 63 patients with a painful bone metastasis who received either magnetic resonance-guided focused ultrasound (MRgFUS) or RT as first-line treatment. Both modalities were effective overall, yielding response rates of >70% at the three-month follow-up evaluation. However, MRgFUS was more efficient, providing a 71% response rate at 1 week after treatment, compared with 26% for RT at that same time point.

The total treatment time and cost of the two modalities were similar, and neither was associated with adverse events above grade 2. Among MRgFUS patients, there was a 14% rate of positioning-related pain and a 33% rate of sonication-related pain, which typically resolved within 1 day after treatment.

Lee et al. report that the median overall survival of patients in the study was 12.7 months in the MRgFUS group and 9.8 months in the RT group, a statistically nonsignificant difference. But the authors emphasize that the study was more about pain relief than extending life. “Reduc[ing] pain, restor[ing] function, and maintain[ing] quality of life is imperative” for those with bone metastasis, the authors conclude. They also caution that MRgFUS is not appropriate for bone metastases of the skull or most of the spine, or for any lesion that is not at least 1 cm away from “tissues at risk.”

Webinar—Helping Clinically Excellent Colleagues Who Have Challenging Behaviors

Sometimes the most talented, skilled physicians with whom you work are also prone to displaying challenging behaviors. Often, these physicians are not cognizant of how their colleagues perceive them, so how can you—as the supervisor, friend, and/or peer of such clinicians—help ensure that patients continue to benefit from their clinical and surgical gifts without behavioral difficulties diminishing their contributions?

On Thursday, October 26, 2017 at 8:00 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary webinar that will deliver practical and effective methods you can use to help physicians who are clinically outstanding, but behaviorally difficult, start to make remedial changes.

speaker pic from oct webinar

The presentations about how to be helpful to such colleagues will be led by:

  • Gerald Hickson, senior VP for Quality, Safety, and Risk Prevention at Vanderbilt University Medical Center
  • William Hopkinson, professor of orthopaedic surgery at Loyola Medicine
  • George Russell, professor and chair of orthopaedic traumatology at the University of Mississippi Medical Center

Moderated by Dr. Douglas Lundy, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.

Seats are limited, so register now!

TEA Proves Durable in Elderly Patients with Distal Humeral Fractures

TEA for OBuzzSeveral studies have demonstrated good short- and intermediate-term outcomes with total elbow arthroplasty (TEA) to treat acute distal humeral fractures. Now, in the September 20, 2017 issue of The Journal of Bone & Joint Surgery, Barco et al. provide data confirming that TEA provides durable pain relief and motion improvements over a minimum of 10 years, albeit with a number of major complications.

Among 44 TEAs performed in elderly patients with and without inflammatory arthritis whom the authors followed for ≥10 years, the mean Mayo Elbow Performance Score was 90.5 points. Five elbows (11%) developed deep infection that required surgical treatment. The revision-free survival rates for elbows with rheumatoid arthritis were 85% at 5 years and 76% at 10 years, while survival rates for elbows without rheumatoid arthritis were 92% at both time points. That difference was not statistically significant, although men in the study were much more likely to experience a revision than women. Twenty-five of the 44 patients died during the long-term follow-up, but the majority of those had their implant in place.

While reporting on these promising long-term revision-free survival rates, Barco et al. emphasize that complications were “frequent and diverse in nature…and have required a reoperation, including implant revision, in 12 of 44 patients.” So, while the good news is that a majority of patients in this situation will die with a useful joint and sound implant, the authors conclude that “surgeons treating this kind of injury should follow their patients over time and should be prepared to manage a wide array of complications using complex techniques.”

Fewer In-Hospital Complications with TAA vs Ankle Fusion

TAA for OBuzzAnkle Fusion for OBuzzAmong the many variables discussed when patients and surgeons make a decision between ankle arthrodesis (fusion) and total ankle replacement (TAA) for end-stage ankle arthritis, in-hospital complication rate is an often-overlooked point of comparison, partly due to a dearth of good data.

In the September 6, 2017 edition of The Journal of Bone & Joint Surgery, Odum et al. report findings from a matched cohort study that compared these two ankle procedures in terms of minor and major perioperative complications. To make more of an apples-to-apples comparison, the authors statistically matched 1,574 patients who underwent a TAA with an equal number of those who underwent fusion.

A major in-hospital complication (such as a pulmonary embolism or mechanical hardware problem) occurred in 8.5% of fusion patients and in 5.3% of TAA patients. After adjusting for case mix, Odum et al. found that ankle arthrodesis was 1.8 times more likely than TAA to be followed by a major complication. Regarding minor in-hospital complications (such as venous thrombosis or hematoma/seroma), the authors found a 29% lower risk of complications among arthrodesis patients compared to TAA patients, although that difference was not statistically significant (p = 0.14). Regardless of surgical procedure, patient age ≤67 years and the presence of multiple comorbidities were independently associated with a higher risk of a major complication.

A possible explanation for the lower in-hospital major-complication rate in TAA patients, say the authors, is that “TAA is more likely to be performed in younger, healthier patients with better bone quality and smaller deformities.”

Peer Review Week Day 5-PM

JBJS is helping celebrate Peer Review Week 2017 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2017, JBJS will profile six different top reviewers on OrthoBuzz each morning and afternoon. This afternoon, let’s meet Brian J.Sennett, Antonia Chen, and Terrence McIff.

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Brian J. Sennett, MD
University of Pennsylvania

What do you like best about reviewing for JBJS?
Improving the level of publications by analytically evaluating articles for submission.  JBJS is such a significant publication that I feel that it is very important that the readership has access to the  best articles.

How do you find time to review for JBJS?
I find time because I  believe it is important.  There is never enough time for everything.  Reviewing for JBJS is one of my priorities.

What do you see as JBJS‘ role in shaping the future of orthopaedics?
I see JBJS as the leader in shaping orthopaedic knowledge and care.  While the annual meeting of the AAOS is a phenomenal meeting, it occurs just once a year.  JBJS allows the readership to stay up-to-date all year long.

 

Antonia_Chen
Antonia Chen, MD
Rothman Institute

What do you like best about reviewing for JBJS?
I am honored at the opportunity to be one of the first to see the latest research that will ultimately shape the future of orthopaedics. It is humbling to play some small part in working with JBJS to provide authors with a critical review of research studies, and ultimately help shape meaningful and impactful manuscripts.

How do you find time to review for JBJS?
I make time for activities that are important to me, and I view reviewing for JBJS as a privilege.

What do you see as JBJS‘ role in shaping the future of orthopaedics?
JBJS provides orthopaedic surgeons with the ultimate voice for our field. It’s a unique balance of cutting edge research and evidence based studies that facilitate sound clinical decisions in the setting of quality, cost-conscious care for our patients.

 

 Terence_Mciff
Terence McIff, MD
University of Kansas Medical Center

What do you like best about reviewing for JBJS?
Very efficient process.  Fast feedback.  I feel like I am contributing to maintain the quality of JBJS and the quality of information that our residents depend on for their education.

How do you find time to review for JBJS?
I do have to put it as one of my priorities.  Sometimes I feel that I just don’t have time for another review but have learned that setting aside specific time to study and complete the review makes it doable.

What do you see as JBJS‘ role in shaping the future of orthopaedics?
JBJS is the standard studied by our orthopedic residents and staff.  As long as it continues to be a trusted source for up-to-date practices and innovations it will serve the community well.