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Displaced Proximal Humeral Fractures: Fix or Replace?

Nonoperative management of proximal humerus fractures in the elderly used to be fairly common, but multiple studies have shown poor outcomes. Open reduction and internal fixation (ORIF) with locked-plate constructs has shown some promise, but it has been fraught with complications. Most recently, reverse total shoulder arthroplasty (rTSA) has emerged as a possible surgical solution, but this is a complicated procedure, and questions have arisen about long-term outcomes.  Compounding this conundrum are the varying degrees of severity of proximal humeral fractures.

In the March 18, 2020 issue of The Journal, Fraser et al. share 2-year results from a multicenter, single-blinded randomized trial that compared rTSA to ORIF for severely displaced proximal humeral fractures in patients 65 to 85 years of age. Included patients (n=124) had OTA/AO 11-B2 or 11-C2 fractures with >45° valgus or >30° varus in the anteroposterior view, or >50% displacement of the humeral head. Using the Constant shoulder score as the primary outcome measure, the authors demonstrated both a statistically significant and clinically meaningful difference favoring rTSA in this cohort.

The mean Constant score was 68.0 points for the rTSA group compared to 54.6 points for the ORIF group. The mean between-group difference, 13.4 points, was significant (p<0.001) and exceeded the minimal clinically important difference of 10 points.  The Constant-score difference between ORIF and rTSA was most pronounced (18.7 points) in patients with C2 fractures, but there was no significant score difference in those with B2 fractures. Secondary outcomes (Oxford Shoulder Scores) showed a consistent trend of the rTSA group scoring higher than the ORIF group at 2 years.

Although this study indicates an advantage for rTSA, one must consider that only severely displaced fractures were investigated and that 2-year follow-up for joint arthroplasty is considered short term. In a Commentary about this article, Peter A. Cole, MD points out that “if there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics.”

Clearly, longer-term studies in this population are a necessity, and Fraser et al. say they plan to follow these patients in 5-year intervals.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Volume-Outcome Relationships in Reverse TSA

In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”

Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.

This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).

Specifically, on the clinical side, Farley et al. found the following:

  • A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
  • A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
  • A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)

Here are the findings from the resource-utilization side:

  • A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
  • A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
  • A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)

Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”

Implant Prices are Main Cost Driver in Joint Replacements

Orthopaedic surgeons have long been aware of the role that implant prices play in the total cost of care for arthroplasty procedures, but methodical breakdowns of implant costs in relation to the cost of other aspects of care have generally been lacking. In the March 4, 2020 issue of The Journal, Carducci et al. detail the impact of implant costs on the total cost of care in a study of 6 lower- and upper-extremity arthroplasty types performed at a single, high-volume orthopaedic specialty hospital.

Using a uniform method called time-driven activity-based costing, the authors calculated the total costs of >22,200 inpatient primary total joint arthroplasties, and then broke down those total costs by categories, including implant price and personnel costs. It was no surprise that, as a percentage of total cost, implant costs were highest for low-volume surgeries (as high as 65% for total ankle arthroplasty) and lowest for high-volume procedures (e.g., 40% for total knee arthroplasty). Nevertheless, across the board, implant price was the most expensive component of total cost.

Implant prices are individually negotiated between a hospital and an implant supplier and are usually protected by nondisclosure agreements, so the data from this investigation may not match up with data from any other institution. Unfortunately, the future of implant-cost research will be tied to the complex issue of return-on-investment for implant-manufacturer stockholders as it relates to negotiations with individual hospitals and health systems.

The profound impact of implant price on the total cost of all the joint arthroplasties studied by Carducci et al. also begs the questions as to how “generic” implants (those not manufactured by the major orthopaedic producers) will ultimately influence the market—and whether “branded” implants, with their 30% to 50% markups, provide any functional benefit for patients. We will need further well-designed research to address those questions.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Rotator Cuff Conundrums: JBJS Webinar-Feb. 24

Rotator cuff tears account for an estimated 4.5 million patient visits per year in the US, which translates into a $3 to $5 billion annual economic burden. Add to that the pain and disability associated with rotator cuff tears, and it’s understandable that many clinical questions arise regarding how best to help patients manage this common condition.

On February 24, 2020 at 8 pm EST, JBJS will host a complimentary 60-minute webinar focused on 2 frequently encountered rotator cuff dilemmas: surgical versus nonsurgical management, and surgical alternatives for irreparable cuff tears that don’t involve joint replacement.

Bruce S. Miller, MD, MS unpacks the findings from his team’s matched-pair analysis in JBJS, which revealed that patients receiving both surgical and nonsurgical management of full-thickness tears experienced pain and functional improvements—but that surgical repair was the “better of two goods.”

Some patients who opt for nonoperative management end up with a chronic, irreparable rotator cuff tear. Teruhisa Mihata, MD, PhD will present findings from his team’s JBJS study, which showed that, after 5 years, healed arthroscopic superior capsule reconstruction in such patients restored function and resulted in high rates of return to recreational sport and work.

Moderated by Andrew Green, MD of Brown University’s Warren Alpert Medical School, the webinar will feature additional expert commentaries. Grant L. Jones, MD will comment on Dr. Miller’s paper, and Robert Tashjian, MD will weigh in on Dr. Mihata’s paper.

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.

Seats are limited, so Register Today!

JBJS Webinar on Feb. 24: Rotator Cuff Conundrums

Rotator cuff tears account for an estimated 4.5 million patient visits per year in the US, which translates into a $3 to $5 billion annual economic burden. Add to that the pain and disability associated with rotator cuff tears, and it’s understandable that many clinical questions arise regarding how best to help patients manage this common condition.

On February 24, 2020 at 8 pm EST, JBJS will host a complimentary 60-minute webinar focused on 2 frequently encountered rotator cuff dilemmas: surgical versus nonsurgical management, and surgical alternatives for irreparable cuff tears that don’t involve joint replacement.

Bruce S. Miller, MD, MS unpacks the findings from his team’s matched-pair analysis in JBJS, which revealed that patients receiving both surgical and nonsurgical management of full-thickness tears experienced pain and functional improvements—but that surgical repair was the “better of two goods.”

Some patients who opt for nonoperative management end up with a chronic, irreparable rotator cuff tear. Teruhisa Mihata, MD, PhD will present findings from his team’s JBJS study, which showed that, after 5 years, healed arthroscopic superior capsule reconstruction in such patients restored function and resulted in high rates of return to recreational sport and work.

Moderated by Andrew Green, MD of Brown University’s Warren Alpert Medical School, the webinar will feature additional expert commentaries. Grant L. Jones, MD will comment on Dr. Miller’s paper, and Robert Tashjian, MD will weigh in on Dr. Mihata’s paper.

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.

Seats are limited, so Register Today!

What’s New in Orthopaedic Rehabilitation 2019

Every month, JBJS publishes 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 such OrthoBuzz summaries.

This month, co-author Nitin B. Jain, MD, MSPH selected the most clinically compelling findings from the 40 studies summarized in the November 20, 2019 “What’s New in Orthopaedic Rehabilitation.

Pain Management
–A randomized controlled trial compared pain-related function, pain intensity, and adverse effects among 240 patients with chronic back, hip, or knee pain who were randomized to receive opioids or non-opioid medication.1 After 12 months, there were no between-group differences in pain-related function. Statistically, the pain intensity score was significantly lower in the non-opioid group, although the difference is probably not clinically meaningful. Adverse events were significantly more frequent in the opioid group.

–A series of nested case-control studies found that the use of the NSAID diclofenac was associated with an increase in the risk of myocardial infarction in patients with spondyloarthritis and osteoarthritis, relative to those taking the NSAID naproxen.2

–Intra-articular injections of corticosteroids or hyaluronic acid are often used for pain relief prior to an eventual total knee arthroplasty (TKA). An analysis of insurance data found that patients who had either type of injection within three months of a TKA had a higher risk of periprosthetic joint infection (PJI) after the operation than those who had injections >3 months prior to TKA.

Partial-Thickness Rotator Cuff Tears
–A randomized controlled trial of 78 patients with a partial-thickness rotator cuff compared outcomes of those who underwent immediate arthroscopic repair with outcomes among those who delayed operative repair until completing 6 months of nonoperative treatment, which included activity modification, PT, corticosteroid injections, and NSAIDs.3 At 2 and 12 months post-repair, both groups demonstrated improved function relative to initial evaluations. At the final follow-up, there were no significant between-group differences in range of motion, VAS, Constant score, or ASES score. Ten (29.4%) of the patients in the delayed group dropped out of the study due to symptom improvement.

Stem Cell Therapy
–A systematic review that assessed 46 studies investigating stem cell therapy for articular cartilage repair4 found low mean methodology scores, indicating overall poor-quality research. Only 1 of the 46 studies was classified as excellent, prompting the authors to conclude that evidence to support the use of stem cell therapy for cartilage repair is limited by a lack of high-quality studies and heterogeneity in the cell lines studied.

References

  1. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872-82.
  2. Dubreuil M, Louie-Gao Q, Peloquin CE, Choi HK, Zhang Y, Neogi T. Risk ofcmyocardial infarction with use of selected non-steroidal anti-inflammatory drugs incpatients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Aug;77(8): 1137-42. Epub 2018 Apr 19.
  3. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med. 2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  4. Park YB, Ha CW, Rhim JH, Lee HJ. Stem cell therapy for articular cartilage repair: review of the entity of cell populations used and the result of the clinical application of each entity. Am J Sports Med. 2018 Aug;46(10):2540-52. Epub 2017 Oct 12.

What’s New in Shoulder and Elbow Surgery 2019

Every month, JBJS publishes 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 such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.

–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4

–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5

Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:

  • Smaller overall lesion size
  • No clear margins of the fragment on MRI
  • Absence of cyst-like lesions

The authors include a nomogram that clinicians can use to predict healing.

UCL Insufficiency
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:

  • Position players returned to play sooner than pitchers, but they had lower rates of return to play.
  • Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).

These findings could help clinicians set expectations for players undergoing UCL reconstruction.

References

  1. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  2. Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
  3. Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
  4. Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
  5. Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
  6. Niu EL, Tepolt FABae DSLebrun DGKocher MSNonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment successJ Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
  7. Camp CL, Conte SD’Angelo JFealy SAFollowing ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequentlyJ Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.

FDA White Paper Cites JBJS “Case Connections” Article

There are 15 references to JBJS studies in the recently published 149-page white paper on “Biological Responses to Metal Implants,” from the FDA’s Center for Devices and Radiological Health. Most of those references are made in Section 7.5.1 (pp. 54-57), which focuses on orthopaedic devices.

The plethora of JBJS references is not surprising, but we were happy also to see that a JBJS “Case Connections” article was cited twice in the white paper. While most of the section on orthopaedic devices discussed metal-on-metal (MoM) hip problems, the FDA noted that adverse biological responses to metals in orthopaedics sometimes occur in the upper extremity. It did so by citing “Adverse Local Tissue Reactions in the Upper Extremity,” which appeared in the May 24, 2017 issue of JBJS Case Connector. The FDA white paper cautioned that metal wear debris-related adverse reactions have occurred with shoulder suture anchors (five cases of which are described in the “Case Connections” article) and with intramedullary humeral nailing (one case of which is described in the “Case Connections” article).

Among the take-home points made by co-authors Thomas Bauer and Allan Harper in the cited “Case Connections” article is this: “Patients with shoulder suture anchors who develop delayed-onset pain and/or stiffness, osteolysis, chondrolysis, or early arthropathy should be evaluated and consideration should be given to the removal of loose or prominent anchors to lessen the risk of articular damage.”

Surgery for Rotator Cuff Tears: The Better of Two Goods

We’re all familiar with the phrase “lesser of two evils,” but I’m an optimist and prefer the phrase “better of two goods.” In the October 2, 2019 issue of JBJS, Ramme et al. compare surgical versus nonsurgical treatment of full-thickness rotator cuff tears. Both cohorts had improved outcomes relative to baseline, but surgical management was the better of two goods.

The authors retrospectively analyzed a prospective cohort of adult patients with full-thickness rotator cuff tears who had elected either surgical or nonsurgical treatment. Ramme et al. utilized propensity score matching to pair up patients in each group according to factors thought to influence outcome, such as age, sex, tear size, chronicity, muscle atrophy, and the Functional Comorbidity Index. This matched-pair analysis is a valiant attempt to eliminate bias that is inherent in retrospective analyses, and this study design also mimics the real-world scenario of shared decision making between physician and patient.

The 2-year follow-up analysis of 107 propensity score-matched patients revealed that both groups improved in 4 patient-reported functional outcomes and pain compared to their baseline measures before treatment. However, the final outcome measurements and magnitude of improvement were statistically greater in the surgical management group (p <0.001).

This study will help shoulder surgeons have more meaningful discussions with their patients about treatment options for full-thickness rotator cuff tears. We know that with proper treatment—either surgical or nonsurgical—patients can expect improvement in pain and function. However, patients who elect surgical management may have the potential for even greater outcomes, and that definitely sounds like the “better of two goods.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Glycation and Rotator Cuff Degeneration

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.

Advanced glycation end products (AGEs) form through a nonenzymatic process by which reducing sugars undergo Maillard rearrangement with amino acids. During rearrangement, the carbonyl group of the sugar reacts with the amino group of the amino acid, producing N-substituted glycosylamine and water.

During cooking, glycation occurs at 140° to 165° C (280° to 330° F), resulting in the browning of foods such as bread and French fries. This nonenzymatic reaction also occurs at human body temperature over decades. AGE formation can decrease the viscoelasticity and tensile strength of human tissue, resulting in increased mechanical stiffness that affects bone, ligaments, cartilage, and menisci. In cartilage, the excessive accumulation of AGEs leads to a more brittle matrix that is susceptible to fatigue and failure. AGEs also contribute to the etiology of several diabetic complications, including adhesive capsulitis of the shoulder.

Rotator cuff degeneration and tears become more common with age. Accumulated mechanical loads and anatomic variation play a large role. The role of AGEs in rotator cuff degeneration and tears has been suspected, but the exact mechanisms remain in question. Investigators recently showed that AGEs have detrimental effects on human rotator cuff-derived cells in vitro and on intact rat infraspinatus tendons ex vivo.1

In Vitro Findings
Rotator cuff-derived cells were obtained from 12 torn cuff edges during supraspinatus tendon repairs in patients with an average age 64.8 years. The cells were cultured in (1) regular medium with 500 μg/mL AGEs (high-AGE group), (2) regular medium with 100 μg/mL AGEs (low-AGE group), and (3) regular medium alone (control group). Cell viability was significantly suppressed in the high-AGE group relative to the control group. Vascular endothelial growth factor secretion was significantly greater in the high- and low-AGE groups than in the control group. Immunofluorescence stain demonstrated enhancement of hypoxia-inducible factor-1α, reactive oxygen species expressions, and cell apoptosis in the high- and low-AGE groups compared with the control group.

Ex Vivo Findings
Four upper limbs with intact rotator cuff tendons were harvested from 10-week old rats and cultured in regular medium or regular medium with 500 μg/mL AGEs. Mechanical testing showed significantly higher tensile strength in the control group than in the AGE group.

These results beg the question as to whether reduction of AGEs might delay or prevent rotator cuff senescence-related degeneration.

Reference

  1. Mifune Y, Inui A, Muto T, Nishimoto H, Kataoka T, Kurosawa T, Yamaura K, Mukohara S, Niikura T, Kokubu T, Kuroda R. Influence of advanced glycation end products on rotator cuff. J Shoulder Elbow Surg. 2019 Aug;28(8):1490-1496. doi: 10.1016/j.jse.2019.01.022. Epub 2019 Apr 10. PMID: 30981546