JBJS 100: ACL Grafts and Wrist Instability
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:
Biomechanical Analysis of Human Ligament Grafts Used in Knee-Ligament Repairs and Reconstructions
F R Noyes, D L Butler, E S Grood, R F Zernicke, M S Hefzy: JBJS, 1984 March; 66 (3): 344
This article set the stage for critically analyzing ACL graft choices based on mechanical properties. Several of the grafts these authors studied had poor strength and are no longer used. Subsequent studies now suggest that several grafts are stronger and stiffer than the native ACL, including bone-patellar tendon-bone grafts. While many other aspects of ACL reconstruction continue to be debated, graft strength and stiffness remain a key consideration.
Traumatic Instability of the Wrist
R L Linscheid, J H Dobyns, J W Beabout, R S Bryan: JBJS, 1972 December; 54 (8): 1612
At a time when orthopaedists were focused primarily on osseous anatomy of the wrist, this article emphasized the importance of assessing carpal alignment and realizing the consequences of disrupted carpal ligaments. Most of the parameters for radiographic assessment of carpal alignment in the article are still relevant today.
What’s New in Sports Medicine 2018
Every 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
- 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.
- 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.
Generalized Joint Laxity—A Risk Factor for Poor Outcomes After ACL Reconstruction
Sometimes, 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.
ACL Trial Quality Has Improved Over Time
The randomized controlled trial (RCT) may be the gold standard of clinical research, but not all RCTs are created equal. In the December 20, 2017 issue of The Journal, Kay et al. set out to determine the historical quality of more than 400 RCTs relating to anterior cruciate ligament (ACL) reconstruction published between 1985 and 2016.
The authors evaluated the studies using the Detsky quality index (on which a score of ≥75% is considered “high” methodological quality) and the CONSORT checklist. Fifty-two percent of the studies analyzed were surgical trials (graft choice, femoral fixation method, and single- vs double-bundle techniques), while 48% were nonsurgical trials (analgesic and rehabilitation regimens).
The mean Detsky score across all studies was 68.9% ± 13.2%. Forty-two percent of the studies were considered high-quality according to Detsky scores. There was no significant difference in mean Detsky scores between surgical and nonsurgical trials.
The authors noted a substantial increase in the number of ACL RCTs over time, although that number has not changed significantly since 2009, which is coincidentally the year that JBJS and many other journals required authors to use the CONSORT flow diagram. Notably, the reporting of methodologically sound randomization processes and the prospective calculation of sample sizes have also improved significantly in recent years.
Both the inclusion of a CONSORT flow diagram and the year published were significant predictors of the quality score. A mere 5% of trials published in 2008 or prior included the CONSORT flow diagram, while >40% of trials published since 2009 had a flow diagram.
While the authors are encouraged that “close to 50% of trials in this study reported blinding of outcome assessors,” they say areas for improvement include better “descriptions of allocation concealment and intent-to-treat analyses.”
Hip Arthroscopy: What and Who Account for Rising Utilization?
Hip arthroscopy for labral pathology and cam and pincer impingement has become increasingly established as an effective procedure in the hands of experienced surgeons. However, as with all technically complex orthopaedic procedures, success entails not only sound technique, but also appropriate patient selection, meticulous pre- and intraoperative setup, and appropriate use of intraoperative fluoroscopy. Thankfully, we have a community of leaders in arthroscopy who share and teach these details.
In the December 20, 2017 issue of The Journal, Duchman et al. use the ABOS Part-II exam database to analyze who among recent graduates of orthopaedic residencies is performing hip arthroscopies. Overall, between 2006 and 2015, the authors found that 643 of 6,987 ABOS candidates (9.2%) had performed ≥1 hip arthroscopy; nearly three-quarters of those reported sports-medicine fellowship training. More than two-thirds of candidates performing hip arthroscopy performed ≤5 such procedures; conversely, only 6.5% of those candidates performed 35% of all the hip arthroscopies identified in the database.
The concerning suggestion from these findings is that the increase in hip arthroscopy utilization comes from an increased number of individuals performing the surgery, rather than from an increase in procedure volume among individual surgeons. One question this study does not address is whether there has been an increase in the prevalence of hip pathology that warrants an increased utilization of this procedure. If not, an alternative explanation, which Wennberg et al. posit in the Dartmouth Atlas, is that procedure utilization expands in relationship to the distribution of provider resources and medical opinion in the local community.
I believe that hip arthroscopy is technically challenging and that the quality of the outcome is very likely related to the per-surgeon volume of procedures performed. This makes it incumbent upon all orthopaedists who offer this procedure to actively evaluate their outcomes with validated instruments so the practitioner and her/his patients can objectively understand and discuss what the results are likely to be.
In a commentary on this study, Rupesh Tarwala, MD calls for an outcomes analysis of patients who were treated with hip arthroscopy by ABOS Part-II candidates. I concur completely, and would more specifically ask that the cohort of surgeons evaluated in this study by Duchman et al. collect and report their 1- and 2-year outcomes to The Journal.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Does Hip Arthroscopy Really Help?
Over the past 15 to 20 years, the use of arthroscopic procedures for hip pathologies has rapidly increased. Leaders in sports medicine have standardized many arthroscopic techniques, including methods of joint distraction, portal location, approaches to labral repair or debridement, and management of cartilage lesions.
Many in the orthopaedic community have wondered whether this expansive use of hip arthroscopy is justified by significant improvement in patient function or is simply a first (and perhaps overused) step toward inevitable hip arthroplasty. To help answer that question, in the June 21, 2017 issue of The Journal, Menge et al. document the 10-year outcomes of arthroscopic labral repair or debridement in 145 patients who originally presented with femoroacetabular impingement (FAI).
Whether these patients were treated with debridement or repair, their functional outcomes and improvement in symptoms were excellent over the 10-year time frame, and the median satisfaction score (10) indicates that these patients were very satisfied overall. However, as seen in other similar studies in the peer-reviewed literature, the results in older patients with significant cartilage injury or radiographic joint space narrowing were inferior, and most of the patients with these characteristics ended up with a hip replacement.
The Menge et al. study helps confirm that arthroscopic repair or debridement in well-selected FAI patients yields excellent longer-term outcomes, and it provides concrete criteria for patient selection.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Sports Medicine Update
Every 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.
The May 17, 2017 JBJS Specialty Update on Sports Medicine reflects evidence in the field of sports medicine published from September 2015 to August 2016. Although this review is not exhaustive of all research that might be pertinent to sports medicine, it highlights many key articles that contribute to the existing evidence base in the field.
Topics covered include:
- Prevention of Musculoskeletal Injuries
- Autograft vs Allograft ACL Reconstruction
- Anterior Shoulder Stabilization
- Hip Arthroscopy
High Rates of Return to Play and Patient Satisfaction after ACL Reconstruction
The estimated annual cost of surgical treatment for anterior cruciate ligament (ACL) ruptures in the US is $2 billion. Are ACL surgery patients—and the health care system—getting significant value for all that money spent?
In the May 3, 2017 issue of The Journal of Bone & Joint Surgery, Nwachukwu et al. set out to answer that question by retrospectively analyzing rates of return to play and satisfaction among 231 ACL-surgery patients (mean age of 27 years) who were followed for a mean of 3.7 years. The authors found that:
- 87% had returned to play at a mean of 10 months after surgery.
- 89% of the 171 athletes eligible to return to their prior level of competition did so.
- 85% said they were “very satisfied” with the outcome, and 98% stated they would have the surgery again.
Not surprisingly, patients were more likely to say they were “very satisfied” if they had returned to play.
The authors also found that the use of patellar tendon autograft increased the chance of returning to play, while preoperative participation in soccer or lacrosse decreased the likelihood of returning to play. Those who participated in basketball, football, skiing, and tennis had higher return-to-play rates than those who participated in the two aforementioned sports.
In addition, Nwachukwu et al. found that one-third of those who did not return to sports reported fear of reinjury as the reason. The authors encourage surgeons to understand that “psychological readiness, fear of reinjury, and mental resiliency influence the probability of an athlete returning to play.”
In her commentary, Elizabeth Matzkin, MD cautions readers to interpret the Level IV study’s findings cautiously. She calls for “better prospective, homogeneous studies” to more accurately assess which surgical graft types and specific sports are more or less likely to result in patients returning to play. Nevertheless, the study, she says, “forces us to look at the big picture: What can we do to make ACL [reconstruction] better for our patients?”
Long-Term, Latarjet Beats Bankart for Anterior Shoulder Instability
In a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.
Specific 10-year outcome comparisons included:
- Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
- Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
- Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
- Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group
Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”
New Key Knee Content from JBJS
The 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 November 2016:
- Comparative Survivorship of Different Tibial Designs in Primary Total Knee Arthroplasty
- All-Polyethylene Versus Metal-Backed Tibial Components
- Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty
- Risk of Total Knee Arthroplasty After Operatively Treated Tibial Plateau Fracture
- Long-Term Clinical Outcomes and Survivorship of Press-Fit Condylar Sigma Fixed-Bearing and Mobile-Bearing Total Knee Prostheses in the Same Patients
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.
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