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What’s New in Spine Surgery 2018

Spine_Graphic for OBuzzEvery 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 Chad Krueger, MD, JBJS Deputy Editor for Social Media, to select the five most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.

Cervical Spine
—A Level-III retrospective analysis found that patients who received a preoperative cervical epidural steroid injection prior to an anterior cervical discectomy and fusion or a posterior cervical fusion had a significantly greater risk of postoperative infection than those who did not receive a preoperative steroid injection.1 Prospective studies are needed to further clarify the perioperative infection risk associated with cervical epidural steroid injections.

Lumbar Spine
—A Level-II randomized pilot trial comparing titanium-coated PEEK interbody spacers with non-coated PEEK spacers among 40 patients who underwent transforaminal lumbar interbody fusion found that patients in both groups had 92% fusion at 3 months, with no significant between-group differences in pain and disability outcomes.2

—A Level-II randomized study of 108 patients who underwent lumbar discectomy compared outcomes among those who experienced 2 weeks versus 6 weeks of postoperative activity restriction. At the 1-year follow-up there was a nonsignificant difference in recurrent herniation (11% in the 2-week group versus 7% in the 6-week group) and no significant between-group differences in pain or disability scores.3

RF Ablation for Chronic Low Back Pain
—A Level-II meta-analysis involving 454 patients with chronic low back pain found that those who underwent radiofrequency (RF) lumbar-facet denervation had significantly reduced VAS back pain compared to a group that underwent a sham procedure or epidural block. Those in the denervation group who benefited most were those who had responded favorably to an initial diagnostic facet block.4

Adolescent Idiopathic Scoliosis
—A Level-II study assessing the ability of surface topography to evaluate spinal deformity in children with adolescent idiopathic scoliosis followed 45 patients for 1 year. This method plus radiography allowed researchers to determine mild curves with strong negative predictive value and sensitivity. The authors estimated that surface topographic analyses could reduce patient exposure to ionizing radiation by eliminating 31% of surveillance radiographs in these patients.5

References

  1. Cancienne JM, Werner BCPuvanesarajah VHassanzadeh HSingla AShen FHShimer ALDoes the timing of preoperative epidural steroid injection affect infection risk after ACDF or posterior cervical fusion?Spine (Phila Pa 1976). 2017 Jan 15;42(2):71-7.
  2. Rickert M, Fleege CTarhan TSchreiner SMakowski MRRauschmann MArabmotlagh MTransforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating: a randomised clinical pilot studyBone Joint J.2017 Oct;99-B(10):1366-72.
  3. Bono CM, Leonard DACha TDSchwab JHWood KBHarris MBSchoenfeld AJThe effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trialEur Spine J.2017 Mar;26(3):905-12. Epub 2016 Nov 2.
  4. Lee CH, Chung CKKim CHThe efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints: a meta-analysis of randomized controlled trialsSpine J.2017 Nov;17(11):1770-80. Epub 2017 May 30.
  5. Hong A, Jaswal NWestover LParent ECMoreau MHedden DAdeeb SSurface topography classification trees for assessing severity and monitoring progression in adolescent idiopathic scoliosisSpine (Phila Pa 1976).2017 Jul 1;42(13):E781-7.

What’s New in Foot & Ankle Surgery 2018

foot-ankle-for-obuzz.jpegEvery 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 Sheldon Lin, MD, a co-author of the May 16, 2018 Specialty Update on Foot and Ankle Surgery, to select the five most clinically compelling findings from among the 60 studies cited in the article.

Ankle Arthroscopy
—A recent Level-I study1 investigated the efficacy of preemptive local anesthesia in combination with general or spinal anesthesia in 80 patients undergoing ankle arthroscopy. The authors found that patients receiving local anesthesia did not require any on-demand pain medication and reported lower pain intensity up to 24 hours post-arthroscopy. Patients in the spinal anesthesia-only group had better pain control than did patients receiving general anesthesia only.

Hallux Rigidus
—While arthrodesis of the first metatarsophalangeal (MTP) joint is the preferred treatment for this condition among most providers, concerns over medial column lengthening and degenerative changes at adjacent joints have led to continued interest in MTP arthroplasty. In a 15-year follow-up of 52 patients randomized to MTP joint arthrodesis or arthroplasty2, Stone et al. found that those who underwent arthrodesis had less pain, fewer revisions, and greater satisfaction than those in the arthroplasty group, with equal function scores. On the basis of these data, arthrodesis remains the treatment of choice for severe hallux rigidus.

Total Ankle Arthroplasty (TAA)
—In a prospective study of 451 patients with an average follow-up of 4.5 years, Lefrancois et al. compared clinical and functional outcomes of 4 TAA prostheses: the HINTEGRA implant, the Agility implant, the Mobility implant, and the Scandinavian Total Ankle Replacement (STAR). Patients with the Mobility implant had less improvement in scores on the Ankle Osteoarthritis Scale, while the other 3 implants had comparable results.

—In a matched cohort study of more than 3,000 patients examining the complication rates of TAA versus those of arthrodesis, Odum et al. found that patients undergoing arthrodesis had a 1.8-times higher risk of a major perioperative complication than those undergoing TAA.

Plantar Fasciitis
—In a randomized controlled trial of 50 patients investigating the efficacy of botulinum toxin for treating plantar fasciitis3, Ahmad et al. found that patients in the botulinum toxin group had improved function and pain scores compared with the placebo group at 6 and 12 months post-injection, as well as a lower rate of surgical treatment for recalcitrant symptoms (0% versus 12%).

References

  1. Liszka H, Gądek A. Preemptive local anesthesia in ankle arthroscopy. Foot Ankle Int. 2016 Dec;37(12):1326-32. Epub 2016 Sep 12.
  2. Stone OD, Ray R, Thomson CE, Gibson JNA. Long-term follow-up of arthrodesis vs total joint arthroplasty for hallux rigidus. Foot Ankle Int. 2017 Apr;38(4):375-80. Epub 2016 Dec 20.
  3. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int. 2017 Jan;38(1):1-7. Epub 2016 Oct 1.

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.

What’s New in Hand and Wrist Surgery 2018

Human Hand Anatomy IllustrationEvery 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, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.

Distal Radius Fractures

—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.1, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.

Scaphoid Fractures

—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.2, which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.

Kienbock Disease

—Lichtman et al.3 introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:

  • How old is the patient?
  • What is the effect of the disease on the lunate?
  • How does the disease affect the wrist?
  • What treatments are available?
  • What are the patient’s requirements?

Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.

Ulnar Impaction

—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.4 noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.

Prescribing Opioids

—Dwyer et al.5 evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.

References

  1. Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
  2. Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
  3. Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
  4. Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
  5. Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.

What’s New in Pediatric Orthopaedics 2018

Pediatrics Image from HUBEvery 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, Derek Kelly, MD, co-author of the February 21, 2018 Specialty Update on Pediatric Orthopaedics, selected the most clinically compelling findings from among the more than 50 studies summarized in the Specialty Update.

Trauma

—An analysis of pediatric femoral shaft fractures before and after the publication of clinical practice guidelines1 revealed a significant increase in the use of interlocked intramedullary nails in patients younger than 11 years of age, and an increase in surgical management for patients younger than 5 years of age. Considerable variability among level-I pediatric trauma centers highlights the need for further outcome studies to facilitate updating of existing guidelines.

Scoliosis

—A prospective cohort study of pain and opioid use among patients following posterior spinal fusion for adolescent idiopathic scoliosis found that increased age, male sex, greater BMI, and preoperative pain levels were associated with increased opioid use. Findings like these may help guide clinicians in opioid dispensing practices that minimize the problem of leftover medication.

Infection

—Two stratification/scoring systems may aid in the early prediction of musculoskeletal infection severity and promote efficient allocation of hospital resources. A 3-tiered stratification system described by Mignemi et al.2 correlated with markers of inflammatory  response and hospital outcomes. Athey et al.3 validated a severity-of-illness score and then modified it for patients with acute hematogenous osteomyelitis.

Hip

—A study of closed reduction for developmental dysplasia of the hip4 revealed that 91% of 87 hips achieved stable closed reduction. Of those, 91% remained stable at the 1-year follow-up. Osteonecrosis occurred in 25% of cases, but it was not associated with the presence of an ossific nucleus, a history of femoral-head reducibility, or age at closed reduction.

—Regardless of obesity status, serum leptin levels increase the odds of slipped capital femoral epiphysis (SCFE), according to a recent study. Researchers reached that conclusion after comparing serum leptin levels in 40 patients with SCFE with levels in 30 BMI-matched controls.

References

  1. Roaten JD, Kelly DM, Yellin JL, Flynn JM, Cyr M, Garg S, Broom A, Andras LM,Sawyer JR. Pediatric femoral shaft fractures: a multicenter review of the AAOS clinical practice guidelines before and after 2009. J Pediatr Orthop.2017 Apr 10. [Epub ahead of print].
  2. Mignemi ME, Benvenuti MA, An TJ, Martus JE, Mencio GA, Lovejoy SA, Copley LA, Williams DJ, Thomsen IP, Schoenecker JG. A novel classification system based on dissemination of musculoskeletal infection is predictive of hospital outcomes. J Pediatr Orthop.2016 Jun 13. [Epub ahead of print].
  3. Athey AG, Mignemi ME, Gheen WT, Lindsay EA, Jo CH, Copley LA. Validation and modification of a severity of illness score for children with acute hematogenous osteomyelitis. J Pediatr Orthop.2016 Oct 12. [Epub ahead of print].
  4. Sankar WN, Gornitzky AL, Clarke NM, Herrera-Soto JA, Kelley SP, Matheney T, Mulpuri K, Schaeffer EK, Upasani VV, Williams N, Price CT; International Hip Dysplasia InstituteClosed reduction for developmental dysplasia of the hip: early-term results from a prospective, multicenter cohort. J Pediatr Orthop.2016 Nov 11. [Epub ahead of print].

What’s New in Adult Reconstructive Knee Surgery 2018, Part II

Knee_smPreviously this month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery. In this OrthoBuzz post, Gwo-Chin Lee, MD, author of the Specialty Update on Adult Reconstructive Knee Surgery, selects his “top five.”

Nonoperative Knee OA Treatment
—Atukorala et al. found a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% of weight loss to achieve a minimal clinically important improvement in function.1

Meniscal Injuries
—A prospective cohort study showed that patients undergoing arthroscopic procedures for degenerative meniscal tears did not have clinically meaningful differences in outcomes compared with patients with traumatic meniscal tears.2

Postoperative Pain Management
—Authors of a Cochrane Systematic Review ascertained that liposomal bupivacaine at the surgical site appears to reduce postoperative pain compared with placebo. However, because of the low quality and volume of evidence, it is not possible to determine its effect compared with conventional agents.3

Avoiding Post-TKA Complications
—In a randomized trial, the use of a tourniquet resulted in upregulation of peptidase activity within the vastus medialis but did not result in an increase in muscular degradation products. The authors concluded that the relationship between tourniquet-induced ischemia and muscle atrophy is complex and poorly understood.4

—The authors of a registry study found no evidence that fondaparinux, enoxaparin, or warfarin are superior to aspirin in the prevention of PE, DVT, or VTE—or that aspirin is safer than these alternatives. However, enoxaparin is as safe as aspirin with respect to bleeding, and fondaparinux is as safe as aspirin with respect to risk of wound complications.5

References

  1. Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is there a dose-response relationship between weight loss and symptom improvement in persons with knee osteoarthritis? Arthritis Care Res (Hoboken). 2016 Aug;68 (8):1106-14.
  2. Thorlund JB, Englund M, Christensen R, Nissen N, Pihl K, Jørgensen U, Schjerning J, Lohmander LS. Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study. BMJ. 2017 Feb 2;356:j356.
  3. Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, Pandit HG. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb 1;2:CD011419.
  4. Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H. Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016 Oct;24(10):3313-21. Epub 2015 Nov 14.
  5. Cafri G, Paxton EW, Chen Y, Cheetham CT, Gould MK, Sluggett J, Bini SA, Khatod M. Comparative effectiveness and safety of drug prophylaxis for prevention of venous thromboembolism after total knee arthroplasty. J Arthroplasty. 2017 Nov;32(11):3524-28.e1. Epub 2017 May 31.

What’s New in Adult Reconstructive Knee Surgery 2018

Knee_smEvery 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery.

Nonoperative Knee OA Treatment

—Intra-articular corticosteroid injections are commonly administered to mitigate pain and inflammation in knee osteoarthritis (OA). However, a randomized controlled trial of 140 patients found that 2 years of triamcinolone injections, when compared with saline injections, resulted in a significantly greater degree of cartilage loss without significant differences in symptoms.1

Non-Arthroplasty Operative Management

—Knee arthroscopy continues to be largely ineffective for pain relief and functional improvement in knee OA. A randomized controlled trial found no evidence that debridement of unstable chondral flaps found at the time of arthroscopic meniscectomy improves clinical outcomes.

Cartilage restoration procedures continue to show varying degrees of success. Long-term results from a randomized trial demonstrated no significant differences in joint survivorship and function between patients undergoing microfracture versus autologous chondrocyte implantation (ACI) at 15 years of follow-up. Nearly 50% of patients in both groups had radiographic evidence of early knee OA.

Periprosthetic Joint Infection

—Periprosthetic joint infection (PJI) remains a leading cause of failure following total knee arthroplasty (TKA). Successful treatment requires accurate diagnosis, and alpha-defensin was found to be both sensitive and specific in the diagnosis of PJI. However, it was not significantly superior to leukocyte esterase (LE) in cases of obvious infection.

—Reported rates of reinfection after 2-stage reimplantation for treatment of a first PJI can be as high as 19%. A 3-month course of oral antibiotics following 2-stage procedures significantly improved infection-free survival without complications.2

Post-TKA Complications from Opioids

—Amid ongoing concerns about opioid misuse, two studies3 suggested that preoperative opioid use was found to be an independent predictor of increased length of stay, complications, readmissions, and less pain relief following TKA.

References

  1. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M,Ward RJ. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. 2017 May 16;317(19):1967-75.
  2. Frank JM, Kayupov E, Moric M, Segreti J, Hansen E, Hartman C, Okroj K,Belden K, Roslund B, Silibovsky R, Parvizi J, Della Valle CJ; Knee Society Research Group. The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial. Clin Orthop Relat Res.2017 Jan;475(1):56-61.
  3. Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty.2017 Sep;32(9):2658-62. Epub 2017 Apr 12.

What’s New in Musculoskeletal Basic Science 2017

Specialty Update Image for OBuzz

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, Matthew J. Allen, VetMB, PhD, author of the December 6, 2017 Specialty Update on Musculoskeletal Basic Science, summarized the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.

Cartilage Repair

–Deriving induced pluripotent stem cells (iPSCs) from peripheral blood cells1 rather than from dermal fibroblasts obviates the need for in vitro expansion. This method may also serve to boost interest in the use of commercial cell-based therapies with defined potency that are available off-the-shelf and don’t require separate cell-harvesting procedures.

–The FDA recommends that large-animal models be used to corroborate basic-science findings from small-animal models. Recent work has demonstrated the efficacy of insulin-like growth factor (IGF)-1 in supporting mechanically competent repair tissue following chondrocyte implantation in a pig model.2

Infection

–Infection, especially from organisms that have developed antimicrobial resistance and/or that produce biofilms, continues to pose a challenging problem for orthopaedic surgeons. To provide a more rational and stratified approach to managing these complex cases, Getzlaf et al. recommend the use of a multidisciplinary approach in which patient-specific information about individual microorganisms is combined with detailed understandings of the vulnerabilities of candidate bacterial species.3

Aseptic Loosening

–There is a resurgence of interest in the role of subclinical infection in the etiopathogenesis of aseptic loosening. At the same time, molecular diagnostic methods for microbial infection are moving forward.4 Such methods may serve to highlight the relevance of subclinical microbial contamination as a cause of aseptic loosening.

Cartilage Imaging

–While the goal of cartilage imaging is to develop tools that are fast, inexpensive, sensitive, accurate, and noninvasive, there is growing interest in the use of more direct, invasive techniques such as optical coherence tomography (OCT),5 which could be used in vivo at the time of surgery to analyze cartilage damage.

References

  1. Li Y, Liu T, Van Halm-Lutterodt N, Chen J, Su Q, Hai Y. Reprogramming of blood cells into induced pluripotent stem cells as a new cell source for cartilage repair. Stem Cell Res Ther.2016 Feb 17;7:31.
  2. Meppelink AM, Zhao X, Griffin DJ, Erali R, Gill TJ, Bonassar LJ, Redmond RW,Randolph MA. Hyaline articular matrix formed by dynamic self-regenerating cartilage and hydrogels. Tissue Eng Part A.2016 Jul;22(13-14):962-70. Epub 2016 Jul 7.
  3. Getzlaf MA, Lewallen EA, Kremers HM, Jones DL, Bonin CA, Dudakovic A,Thaler R, Cohen RC, Lewallen DG, van Wijnen AJ. Multi-disciplinary antimicrobial strategies for improving orthopaedic implants to prevent prosthetic joint infections in hip and knee. J Orthop Res.2016 Feb;34(2):177-86. Epub 2015 Dec 29.
  4. Palmer MP, Melton-Kreft R, Nistico L, Hiller NL, Kim LH, Altman GT, Altman DT, Sotereanos NG, Hu FZ, De Meo PJ, Ehrlich GD. Polymerase chain reaction-electrospray-time-of-flight mass spectrometry versus culture for bacterial detection in septic arthritis and osteoarthritis. Genet Test Mol Biomarkers.2016 Dec;20(12):721-31. Epub 2016 Oct 17.
  5. Novakofski KD, Pownder SL, Koff MF, Williams RM, Potter HG, Fortier LA. High-resolution methods for diagnosing cartilage damage in vivo. 2016 Jan;7(1):39-51.

What’s New in Orthopaedic Rehabilitation 2017

Specialty Update Image for OBuzzEvery 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, Nitin Jain, MD, MSPH, a co-author of the November 15, 2017 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the nearly 50 noteworthy studies summarized in the article.

Pain Management
–Results from a retrospective review1 of patients with noncancer pain highlighted that the risks of long-acting opioids extend beyond overdose, and include increased risks of cardiovascular death and all-cause mortality.

–A randomized prospective trial2 comparing celecoxib, ibuprofen, and naproxen for treating arthritis pain found no significant difference in the hazard ratios for those medications as related to risk of cardiovascular events.

Cost & Quality
–An assessment of a value-improvement initiative3 that examined hip and knee arthroplasty and hip fracture outcomes in a large regional health-care system found reduced costs and improvements in quality of care from 2012 to 2016.

Concussion
–A literature review4 of 7 studies determined that the long-term cognitive and neurogenerative effects of multiple concussions in patients ≤17 years of age remain inconclusive.

Spine
–A randomized trial5 found no difference between anesthetic-only and anesthetic-plus-steroid epidural injections in the treatment of lumbar spinal stenosis.

Shoulder
–A prospective cohort study6 by the MOON Shoulder Group found that the strongest predictor of failure of nonoperative treatment for symptomatic atraumatic rotator cuff tears was lower patient expectations that such treatment would be successful. Pain level, duration of symptoms, and tear anatomy did not predict treatment failure.

References

  1. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415-23.
  2. Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME,Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V,Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
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What’s New in Hip Replacement 2017

THA for OBuzzEvery 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, James T. Ninomiya, MD, MS, lead author of the September 20, 2017 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 50 studies covered in the Specialty Update.

Obesity and THA Outcomes
–Obesity is a well-established risk factor for perioperative THA complications. A prospective registry-based study found that reoperation and implant revision or removal rates increased with increasing BMI. More specifically, increasing BMI was associated with increased rates of early hip dislocation and deep periprosthetic infection.

Infection Prevention
–Two studies 1, 2 demonstrated that patients who have intra-articular injections within 3 months prior to THA experienced nearly double the risk of periprosthetic infection in the first postoperative year, compared with those in noninjection control groups.

Surgical Approaches to THA
–A study of >2,100 patients revealed that, despite claims to the contrary, there were no differences in dislocation rates between those who underwent THA using the direct anterior approach and a propensity-score matched cohort who underwent THA using a posterior approach.3

OR Temperature
–What is the optimal temperature for an orthopaedic operating room? Anecdotes are often used to justify keeping operating rooms at uncomfortably high temperatures, which leads to discomfort and fatigue for members of the surgical team. A comprehensive literature review led authors to suggest that preoperative patient warming, intraoperative patient warming with forced-air devices, and keeping OR temperature at ≤19° C is the ideal combination for comfort while still maximizing patient safety and outcomes.

Return to Driving
–Following joint replacement, patients often ask when it will be safe to return to driving. A meta-analysis of 19 studies concluded that the mean time for return to baseline reaction time for braking was 2 weeks following a right-sided hip replacement and 4 weeks following a right-sided knee replacement.4 The authors stressed, however, that return-to-driving recommendations should be individualized for each patient.

References

  1. Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):166–169.e1. Epub 2016 Apr 22.
  2. Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016 ;31(4):820–3. Epub 2015 Sep 1.
  3. Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):127–30. Epub 2016 Mar 15.
  4. van der Velden CA, Tolk JJ, Janssen RPA, Reijman M. When is it safe to resume driving after total hip and total knee arthroplasty? A meta-analysis of literature on post-operative brake reaction times. Bone Joint J. 2017 ;99-B(5):566–76.