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What’s New in Musculoskeletal Infection

PPI Image for O'BuzzEvery 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, Arvind Nana, MD, co-author of the July 19, 2017 Specialty Update on musculoskeletal infection, selected the five most compelling findings from among the more than 120 studies cited in the Specialty Update.

Periprosthetic Joint Infection

–Much of the discussion around treating periprosthetic joint infections (PJIs) centers around comparing one-stage versus two-stage exchange arthroplasty. Two-stage exchange arthroplasty requires the use of a temporary cement spacer, and one study1 found that debris from articulating spacers may induce CD3, CD20, CD11(c), and IL-17 changes, raising the possibility of associated immune modulation.

–When performing debridement to treat a PJI, instead of an irrigation solution containing antibiotics, a 20-minute antiseptic soak with 0.19% vol/vol acetic acid reduced the risk of reinfection.2

Spine

–Four studies helped bolster evidence that surgical-site infections are the leading cause of reoperations after spine surgery, both early (within 30 days)3, 4 and late (after 2 years).5, 6

Trauma

–A 100-patient prospective cohort study found that posttraumatic osteomyelitis treated with a 1-stage protocol and host optimization in Type B hosts resulted in 96% infection-free outcomes.7

Shoulder

–As in lower-extremity procedures, the risk of infection after shoulder arthroplasty and arthroscopy is higher when the surgeries are performed less than 3 months after a corticosteroid injection. This finding suggests elective shoulder procedures should be delayed for at least 90 days after such injections.8

References

  1. Singh G, Deutloff N, Maertens N, Meyer H, Awiszus F, Feuerstein B, Roessner A, Lohmann CH. Articulating polymethylmethacrylate (PMMA) spacers may have an immunomodulating effect on synovial tissue. Bone Joint J. 2016 ;98-B(8):1062–8.
  2. Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic acid as part of a debridement protocol during revision total knee arthroplasty. J Arthroplasty. 2017 ;32(3):953–7. Epub 2016 Sep 28.
  3. Medvedev G, Wang C, Cyriac M, Amdur R, O’Brien J. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016 ;41(19):1477–83.
  4. Hijas-Gómez AI, Egea-Gámez RM, Martínez-Martín J, González-Díaz RC, Losada-Viñas JI, Rodríguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain. Spine. November 2016.
  5. Ohya J, Chikuda H, Takeshi O, Kato S, Matsui H, Horiguchi H, Tanaka S, Yasunaga H. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese diagnosis procedure combination database. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 22.
  6. Ahmed SI, Bastrom TP, Yaszay B, Newton PO; Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 9.
  7. McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 ;98-B(9):1289–96.
  8. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 ;25(3):390–7. Epub 2015 Nov 30.

What’s New in Orthopaedic Trauma

Trauma Image for OBuzz.pngEvery 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, David Teague, MD, co-author of the July 5, 2017 Specialty Update on orthopaedic trauma, selected the five most clinically compelling findings from among the 34 studies summarized in the Specialty Update.

Tibial Fractures
A randomized, sham-controlled clinical trial1 failed to demonstrate improved functional recovery or accelerated radiographic healing with the addition of low-intensity pulsed ultrasound (LIPUS) to the postoperative regimen of fresh tibial fractures.

Postsurgical Weight-Bearing
Two studies support early weight-bearing (WB) after certain operatively managed lower extremity injuries, an allowance that may substantially improve a patient’s early independence. One randomized study2demonstrated that immediate WB after locked intramedullary fixation of tibial fractures is not inferior in union time, complication rates, or early function score when compared with a 6-week period of non-WB. The second randomized trial3 found early WB after select ankle fracture fixation (no syndesmosis or posterior malleolar fixation included) resulted in no increase in complications, fewer elective implant removals, and improved 6-week function, relative to late weight-bearing.

Pelvic Injuries
The addition of posterior fixation to anterior fixation for patients with anteroposterior compression type-2 injuries (symphysis disruption, unilateral anterior sacroiliac joint widening) improved radiographic results and led to fewer anterior plate failures.

Hip Fractures
Less femoral neck shortening occurred with cephalomedullary nail fixation devices (2 mm) than with a side plate and lag screw construct (1 cm) when treating OTA/AO 31-A2 intertrochanteric fractures (unstable, 3 or more parts) in patients ≥55 years of age, although functional outcomes were similar for the two groups.

References

  1. Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH; TRUST Investigators writing group. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016 ;355:i5351.
  2. Gross SC, Galos DK, Taormina DP, Crespo A, Egol KA, Tejwani NC. Can tibial shaft fractures bear weight after intramedullary nailing? A randomized controlled trial. J Orthop Trauma. 2016 ;30(7):370–5.
  3. Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016 ;30(7):345–52.

What’s New in Spine Surgery

Spine for O'Buzz.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 Theodore Choma, MD, co-author of the June 21, 2017 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies cited in the article.

Biomaterials and Biologics

A multicenter randomized prospective trial compared osteogenic protein-1 (OP-1, also known as bone morphogenetic protein [BMP]-7) combined with local autograft to iliac crest autograft combined with local autograft in posterolateral lumbar fusion. Based on computed tomography (CT) scan assessments, the authors found a 54% fusion rate in the OP-1 group and a 74% fusion rate in the iliac crest group. OP-1 appears to be a poor substitute for iliac crest autograft for achieving posterolateral lumbar fusion.

Adult Spinal Deformity (ASD)

We continue to elucidate the risks and morbidity of adult degenerative spinal deformity surgery. The Scoli-Risk-1 study,1 a Level-III multicenter, prospective observational study, reported on 272 patients with ASD treated surgically. Twenty-two percent of the patients were discharged from the hospital with a decline in the lower-extremity motor score, while only 13% demonstrated improvement. However, by 6 months postoperatively, 21% demonstrated improvement, 69% demonstrated maintenance, and 11% continued to demonstrate lower-extremity motor decline.

Spinal Cord Injury

A Level-I, randomized, crossover trial2 examined whether the character of neuropathic pain following spinal cord injury determined the response to 300 mg/day of either pregabalin or oxcarbazepine. Both anticonvulsant medications significantly improved neuropathic pain in these patients. A subgroup analysis demonstrated that oxcarbazepine was more effective in patients without evoked pain and pregabalin was more effective in patients with evoked pain.

Lumbar Degenerative Spondylolisthesis

To address the consequences of fusion along with decompression in degenerative lumbar spondylolisthesis, a Level-I, randomized controlled trial3 specifically compared laminectomy only with laminectomy plus fusion among 66 patients with stable degenerative spondylolisthesis and symptomatic lumbar stenosis. Patients in the fusion group had significantly higher SF-36 scores at 2, 3, and 4 years, but the groups did not differ with respect to ODI scores at 2 years. The authors reported a significantly higher reoperation rate (34% compared with 14%) in the decompression-only group over the 4-year follow-up, but patients who underwent decompression with fusion began to have an increase in the probability of reoperation 36 months after surgery.

Osteoporotic Injuries

We have more evidence of the effectiveness of vertebral cement augmentation for osteoporotic thoracolumbar compression fractures. The authors of a level-I systematic review and meta-analysis examined randomized controlled trials comparing vertebroplasty with conservative treatment or placebo/sham and identified 11 relevant studies involving 1,048 subjects. The meta-analysis found that patients receiving percutaneous vertebroplasty (n = 531) had lower pain ratings at 1 to 2 weeks, 2 to 3 months, and 1 year. The effect size of vertebroplasty was significant and close to the minimal clinically important difference (MCID).

References

  1. Lenke LG, Fehlings MG, Shaffrey CI, Cheung KM, Carreon L, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellis´e-Urquiza F, Lewis SJ, Berven SH. Neurologic outcomes of complex adult spinal deformity surgery: results of the prospective, multicenter Scoli-RISK- 1 study. Spine (Phila Pa 1976). 2016 Feb;41(3):204-12.
  2. Min K, Oh Y, Lee SH, Ryu JS. Symptom-based treatment of neuropathic pain in spinal cord-injured patients: a randomized crossover clinical trial. Am J Phys Med Rehabil. 2016 ;95(5):330–8
  3. Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JV, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VK, Barker FG 2nd, Benzel EC. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016 Apr 14;374(15):1424-34.

Sports Medicine Update

What's_New_Sports_Med_Image_for_O'Buzz.pngEvery 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

What’s New in Foot and Ankle Surgery

Foot xray for fott and ankle O'Buzz.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, co-author of the April 19, 2017 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies cited in the article.

VTE Prevention

–Recommendations for venous thromboembolism (VTE) prophylaxis in isolated foot and ankle fractures are conflicting. In a prospective study, Zheng et al.1 determined the incidence of VTE in 814 patients who received either low-molecular-weight heparin or placebo for 2 weeks postoperatively. The overall incidence of deep vein thrombosis was 0.98% in the heparin group and 2.01% in the placebo group, with no significant difference between the two. The risk factors were high body mass index (BMI) and advanced age. The authors concluded that routine chemical prophylaxis was not necessary in cases of isolated foot and ankle fractures.

Age and Total Ankle Arthroplasty

–Concerns regarding implant survivorship in younger patients have prompted investigations into the effect of age on total ankle arthroplasty outcomes. Demetracopoulos et al.2 prospectively compared patient-reported outcomes and revision rates in patients who were 70 years of age. At the 3.5-year follow-up, patients who were 70 years of age, although no differences were observed in pain, need for reoperation, or revision rates between groups.

Hallux Rigidus/Hallux Valgus

–Joint-preserving arthroplasties for hallux rigidus have been proposed as an alternative to first metatarsophalangeal joint arthrodesis. However, they have shown high rates of failure with associated bone loss, rendering salvage arthrodesis a more complicated procedure with worse outcomes. A Level-I study by Baumhauer et al.3 investigated the use of a synthetic cartilage implant that requires less bone resection than a traditional arthroplasty. Patients were randomized to implant and arthrodesis groups. At the 2-year follow-up, pain level, functional scores, and rates of revision surgical procedures were statistically equivalent in both groups. Secondary arthrodesis was required in <10% of the implant group and was considered to be a straightforward procedure because of preservation of bone stock.

–Hallux valgus surgical procedures are commonly performed under spinal, epidural, or regional anesthesia. Although peripheral nerve blocks have become increasingly popular with the advent of ultrasound, the associated learning curve has limited more widespread use. A Level-I study by Karaarslan et al.4 compared the efficacy of ultrasound-guided popliteal sciatic nerve blocks with spinal anesthesia in patients undergoing hallux valgus correction. The popliteal block group demonstrated decreased pain scores at every time point up to 12 hours postoperatively, longer time to first analgesic requirement, and increased patient satisfaction scores compared with the spinal anesthesia group. The popliteal block group also did not experience the adverse effects of hypotension, bradycardia, and urinary retention occasionally seen with spinal anesthesia.

Orthobiologics

–Orthobiologics continue to generate considerable interest within the orthopaedic community. Platelet-rich plasma and hyaluronic acid have been investigated as adjuncts to promote healing. In a Level-I study, Görmeli et al.5 randomized patients to receive platelet-rich plasma, hyaluronic acid, or saline solution injections following arthroscopic debridement and microfracture of talar osteochondral lesions. At the intermediate-term follow-up, the platelet-rich plasma and hyaluronic acid groups exhibited a significant increase in AOFAS scores and decrease in pain scores compared with the control group, with the platelet-rich plasma group showing the greatest improvement.

References

  1. Zheng X, Li DY, Wangyang Y, Zhang XC, Guo KJ, Zhao FC, Pang Y, Chen YX. Effect of chemical thromboprophylaxis on the rate of venous thromboembolism after treatment of foot and ankle fractures. Foot Ankle Int. 2016 Nov;37(11):1218-24.
  2. Demetracopoulos CA, Adams SB Jr, Queen RM, DeOrio JK, Nunley JA 2nd, Easley ME. Effect of age on outcomes in total ankle arthroplasty. Foot Ankle Int. 2015 Aug;36(8):871-80.
  3. Baumhauer JF, Singh D, Glazebrook M, Blundell C, De Vries G, Le ILD Nielsen D, Pedersen ME, Sakellariou A, Solan M, Wansbrough G, Younger AS, Daniels T; for and on behalf of the CARTIVA Motion Study Group. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot Ankle Int. 2016 May;37(5):457-69.
  4. Karaarslan S, Tekg¨ul ZT, S¸ ims¸ek E, Turan M, Karaman Y, Kaya A, Gönüllü M. Comparison between ultrasonography-guided popliteal sciatic nerve block and spinal anesthesia for hallux valgus repair. Foot Ankle Int. 2016 Jan;37(1):85-9. Epub 2015 Aug 20.
  5. Görmeli G, Karakaplan M, Görmeli CA, Sarıkaya B, Elmalı N, Ersoy Y. Clinical effects of platelet-rich plasma and hyaluronic acid as an additional therapy for talar osteochondral lesions treated with microfracture surgery: a prospective randomized clinical trial. Foot Ankle Int. 2015 Aug;36(8):891-900.

What’s New in Hand and Wrist Surgery

Hand Wrist for O'Buzz.jpegEvery month, JBJS publishes a Specialty Update—a review of some of the most pertinent and impactful studies published in one of 13 orthopaedic subspecialties during the previous year. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 15, 2017 Specialty Update on hand and wrist surgery, to select five of the most clinically compelling findings from among the more than 40 he cited in the article.

Carpal Tunnel Syndrome

—The AAOS published updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome (CTS). Among the conclusions are the following:

  • Thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out.
  • High body mass index and repetitive hand and wrist actions are associated with an increased risk of developing CTS.
  • Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment.
  • There is no benefit to routine postoperative immobilization after CTS surgery.

Wrist Fracture

—If a distal radius fracture is displaced, especially in an elderly patient, should one proceed with nonoperative or operative treatment? A systematic review/meta-analysis1 involving more than 800 patients 60 years of age or older found that operatively treated patients had greater grip strength and better restoration of radiographic parameters than nonoperatively treated patients. However, those who underwent surgery also experienced more complications (primarily hardware-related) that required surgery.

Thumb and Digit Arthritis

—There are a myriad of treatments for the management of basilar thumb arthritis, ranging from trapeziectomy to fusion. Which one is better, especially if the scaphotrapeziotrapezoid joint is not involved? A prospective study was conducted randomizing women older than 40 with basal thumb joint arthritis to trapeziectomy and suspension arthroplasty or carpometacarpal joint arthrodesis. After a mean follow-up of 5.3 years, those in the trapeziectomy-suspension arthroplasty group had significantly better pain reduction and function.2 Researchers halted the study prematurely due to increased complications in the arthrodesis group.

Outcome Measurement Tools

—Among the many patient-reported outcome measures for the upper extremity, which should be used for which conditions? For distal radius fractures, a systematic approach has been proposed3 that captures outcomes across five domains: range of motion and grip strength, patient-reported scores of disability and function, complications, pain, and radiographs.4

—Is there any way to make the collection of patient-reported outcomes easier and less time-consuming? An assessment that compared two forms of computerized adaptive tests (CATs) with the DASH (Disabilities of the Arm, Shoulder and Hand) measure among 379 hand-clinic patients found that the CAT required fewer questions to complete than the DASH, yet maintained excellent reliability.5

References

  1. Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients. A systematic review and meta-analysis. J Hand Surg Am. 2016 ;41(3):404–13. Epub 2016 Jan 20.
  2. Spekreijse KR, Selles RW, Kedilioglu MA, Slijper HP, Feitz R, Hovius SE, Vermeulen GM. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a 5-year follow-up. J Hand Surg Am. 2016 ;41(9):910–6.
  3. Teunis T, Ring D. Comprehensive outcome assessment after distal radius fracture. J Hand Surg Am. 2016 ;41(8):e257. Epub 2016 Jun 11.
  4. Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Distal Radius Outcomes Consortium. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565–73.
  5. Beckmann JT, Hung M, Voss MW, Crum AB, Bounsanga J, Tyser AR. Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test. J Hand Surg Am. 2016 ;41(7):739–744.e4. Epub 2016 Jun 3.

What’s New in Pediatric Orthopaedics

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, Derek Kelly, MD, co-author of the February 15, 2017 Specialty Update on Pediatric Orthopaedics, selected the five most clinically compelling findings from among the 60 studies summarized in the Specialty Update.

Upper-Extremity Trauma
—A systematic review of eight randomized studies comparing splinting with casting for distal radial buckle fractures confirmed that splinting was superior in function, cost, and convenience, without an increased complication rate.1

Lower-Extremity Trauma
—A review of the treatment of 361 pediatric diaphyseal femoral fractures before and after the 2009 publication of AAOS clinical guidelines for treating such fractures revealed that the guidance had little impact on the treatment algorithm in one pediatric hospital.

Spine
—Bracing remains an integral part of managing adolescent idiopathic scoliosis, but patient compliance with brace wear is variable. A prospective study of 220 patients demonstrated that physician counseling based on compliance-monitoring data from sensors embedded in the brace improved patients’ average daily orthotic use.

Hip
—AAOS-published evidence-based guidelines on the detection and nonoperative management of developmental dysplasia of the hip (DDH) in infants from birth to 6 months of age determined that only two of nine recommendations gleaned from evidence in existing literature could be rated as “moderate” in strength:

  • Universal DDH screening of all newborn infants is not supported.
  • Imaging before 6 months is supported if the infant has one or more of three listed risk factors.

Seven additional recommendations received only “limited” strength of support.

—A study of the utility of inserting an intraoperative intracranial pressure (ICP) monitor during closed reduction and pinning for slipped capital femoral epiphysis (SCFE) found that 6 of 15 unstable hips had no perfusion according to ICP monitoring. However, all 6 hips were subsequently reperfused with percutaneous capsular decompression, and no osteonecrosis developed over the next 2 years.

Reference

  1. Hill CE, Masters JP, Perry DC. A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist. J Pediatr Orthop B. 2016 ;25(2):183–90.

What’s New in Adult Reconstructive Knee Surgery

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, Gwo-Chin Lee, MD, author of the January 18, 2017 Specialty Update on Adult Reconstructive Knee Surgery, selected the five most clinically compelling findings from among the more than 100 studies summarized in the Specialty Update.

Nonoperative Knee OA Treatment

—Weight loss is one popular nonoperative recommendation for treating symptoms of knee osteoarthritis (OA). An analysis of data from  the Osteoarthritis Initiative found that delayed progression of cartilage degeneration, as revealed on MRI and clinical symptoms, positively correlated with BMI reductions >10% over 48 months.1

Total Knee Arthroplasty

—In total knee arthroplasty (TKA), the drive toward producing normal anatomy has led to explorations of alternative alignment paradigms. A prospective randomized study found that small deviations from the traditional mechanical axis (known as kinematic alignment) can be well tolerated and do not lead to decreased survivorship or poorer functional outcomes at short-term follow up.2

—Controversy exists about the optimal method to achieve stemmed implant fixation in revision TKA.  A randomized controlled trial of TKA patients with mild to moderate tibial bone loss found no difference in tibial implant micromotion between cemented and hybrid press-fit stem designs, based on radiostereometric analysis.

Blood Management in TKA

—Minimizing blood loss and transfusions is crucial to minimizing complications after TKA. A randomized, double-blind, placebo-controlled trial found that intra-articular and intravenous administration of tranexamic acid (TXA) was more effective than intravenous TXA alone, without an increased risk of venous thromboembolism (VTE).  However, the optimal regimen for TXA remains undefined.

VTE/PE Prophylaxis

—VTE prophylaxis is essential for all patients undergoing TKA. A risk-stratification study of pulmonary embolism (PE) after elective total joint arthroplasty reported that the incidence of PE within 30 days after either hip or knee replacement was 0.5%. Risk factors associated with PE were age of > 70 years, female sex, and higher BMI. The presence of anemia was protective against PE.  The authors developed an easy-to-use scoring system to determine risk for VTE to help guide chemical prophylaxis.3

References

  1. Gersing AS, Solka M, Joseph GB, Schwaiger BJ, Heilmeier U, Feuerriegel G, Nevitt MC, McCulloch CE,Link TM. Progression of cartilage degeneration and clinical symptoms in obese and overweight individuals is dependent on the amount of weight loss: 48-month data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2016 Jul;24(7):1126-34. Epub 2016 Jan 30.
  2. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M. PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 27. [Epub ahead of print]
  3. Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and validation of a risk stratification system for pulmonary embolism after elective primary total joint arthroplasty. J Arthroplasty. 2016 Sep;31(9)(Suppl):187-91. Epub 2016 Mar 17.

 

What’s New in Orthopaedic Rehabilitation

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, Nitin Jain, MD, MSPH, a co-author of the November 16, 2016 Specialty Update on Orthopaedic Rehabilitation, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.

Back Pain

–A prospective cohort study1 evaluating the benefit of early imaging (within 6 weeks of index visit) for patients ≥65 years old with new-onset back pain found that those with early imaging had significantly higher resource utilization and expenditures compared with matched controls who did not undergo early imaging. One year after the index visit, authors found no significant between-group differences in patient-reported pain or disability. They concluded that “early imaging should not be performed routinely for older adults with acute back pain.”

–A randomized clinical trial2 comparing 10 days of NSAID monotherapy with 10 days of NSAIDs + muscle relaxants or opioids for acute nonradicular low back pain found no significant differences across the groups for pain, functional impairment, or use of health care resources. The authors said these findings suggest that combination therapy is not better than monotherapy in this situation, and that the use of opioids in such patients is not indicated.

Rotator Cuff Tears

–A two year follow-up of a randomized trial comparing three treatments for supraspinatus tears (physiotherapy, physiotherapy + acromioplasty, and rotator cuff repair + acromioplasty +physiotherapy) found no significant pain or function differences among the three groups. However, mean tear size was significantly smaller in the cuff-repair group than in the other two.

Pain Medicine

–A meta-analysis3 investigating the use of cannabinoids for managing chronic pain and spasticity concluded that those substances reduced pain and spasticity more than placebo, but the benefits came with an increased risk of side effects such as dizziness, nausea, confusion,  and loss of balance.

Psychosocial Factors

–A randomized controlled trial4 comparing a phone-based cognitive-behavioral/physical therapy (CBPT) program to standard education following lumbar spine surgery found that patients in the CBPT group had greater decreases in pain and disability and increases in general health and physical performance.

References

  1. Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW,Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar17;313(11):1143-53.
  2. Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
  3. Whiting PF, Wolff RF, Deshpande S, DiNisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73.
  4. Skolasky RL, Maggard AM, Li D, Riley LH 3rd., Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil. 2015 Jul;96(7):1200-7. Epub 2015 Mar 28.

What’s New in Shoulder and Elbow Surgery

reverse_TSA.pngEvery 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, Aaron Chamberlain, MD, MSc, a co-author of the October 19, 2016 Specialty Update on Shoulder and Elbow Surgery, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.

Reverse Shoulder Arthroplasty

Optimizing reverse shoulder arthroplasty implant design continues to be a research focus. There is significant variation among different implants with regard to the amount of lateralization of the center of rotation, and how lateralization affects clinical outcomes is of particular interest.  Authors randomized patients to undergo reverse shoulder arthroplasty with a center of rotation at the native glenoid face or with lateralization.1  Postoperative functional results at a mean follow-up of 22 months were similar between groups overall.  However, when the analysis excluded patients with teres minor muscle degeneration, patients with a more lateralized center of rotation had a greater improvement in external rotation.  This may portend a benefit of lateralization in the setting of an intact posterior rotator cuff.

Rotator Cuff Tear Natural History

A Level-I prospective cohort study of patients with asymptomatic rotator cuff tears evaluated patterns of tear progression over time.2 Of specific interest was whether the integrity of the anterior supraspinatus cable influenced tear size and/or risk for tear enlargement.  Cable-disrupted tears were 9 mm larger at baseline, but cable integrity did not influence risk for tear enlargement or time to enlargement.  This understanding may help inform patient discussions about the risks of nonoperative management of rotator cuff tears.

Rotator Cuff Repair

Do patients with symptomatic degenerative rotator cuff tears fare better with surgery or nonoperative management?   Only three prospective randomized trials have been published comparing outcomes after randomizing patients to nonoperative management or surgical repair. This Level-I trial randomized patients (mean age of 61) with degenerative full thickness cuff tears to either a course of non-operative management (corticosteroid injection, physical therapy, and oral analgesics) or surgical rotator cuff repair. 3 Patients who underwent surgery experienced a greater reduction in VAS pain and VAS disability scores compared with the nonoperative cohort at 1 year of follow-up.

In another prospective randomized study, authors randomized patients who were ≥55 years of age with painful degenerative supraspinatus tears into one of three treatments: 1) physical therapy alone, 2) acromioplasty and physical therapy, and 3) rotator cuff repair, acromioplasty, and physical therapy. Patients in this study were older than those in the study mentioned above, with a mean age of 65 (range 55 to 81).  At the 2-year follow-up, no significant differences among the three interventions were seen in the Constant score, VAS pain score, or patient satisfaction. This data supports initial conservative treatment in older patients with degenerative atraumatic cuff tears.  However, the importance of tear progression over time and the age threshold that separates “older” patients from “younger” patients remain to be determined.

Biological Supplementation

Can we improve the biologic healing environment for rotator cuff repair healing? A Level-I prospective randomized controlled study evaluated leukocyte and platelet-rich fibrin in rotator cuff repairs.4 Patients underwent arthroscopic rotator cuff repair with and without leukocyte and platelet-rich fibrin applied to the repair site. No beneficial effect of leukocyte and platelet-rich fibrin was found in overall clinical outcome, healing rate, postoperative defect size, and tendon quality at the 1-year follow-up.  A reliable biological augmentation solution for rotator cuff healing remains elusive.

References

1            Greiner S, Schmidt C, Herrmann S, Pauly S, Perka C. Clinical performance of lateralized versus non-lateralized reverse shoulder arthroplasty: a prospective randomized study. J. Shoulder Elbow Surg. [Internet]. 2015;24(9):1397–404. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002864doi:10.1016/j.jse.2015.05.041

2            Keener JD, Hsu JE, Steger-May K, Teefey SA, Chamberlain AM, Yamaguchi K. Patterns of tear progression for asymptomatic degenerative rotator cuff tears. J. Shoulder Elbow Surg. [Internet]. 2015 Dec 1;24(12):1845–1851. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615004759

3            Lambers Heerspink FO, van Raay JJAM, Koorevaar RCT, van Eerden PJM, Westerbeek RE, van ’t Riet E, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J. Shoulder Elbow Surg. [Internet]. 2015;24(8):1274–81. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002852doi:10.1016/j.jse.2015.05.040

4            Zumstein MA, Rumian A, Thélu CÉ, Lesbats V, O’Shea K, Schaer M, et al. SECEC Research Grant 2008 II: Use of platelet- and leucocyte-rich fibrin (L-PRF) does not affect late rotator cuff tendon healing: a prospective randomized controlled study. J. Shoulder Elbow Surg. [Internet]. 2016 Jan 1;25(1):2–11. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615005388