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What’s New in Pediatric Orthopaedics 2019

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.

This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.

Pediatric Trauma
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.

—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1

Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a  minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.

Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).

Clubfoot
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.

References

  1. Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
  2. Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].

What’s New in Reconstructive Knee Surgery 2019

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries. This month, Michael J. Taunton, MD, author of the January 16, 2019 “What’s New in Adult Reconstructive Knee Surgery,” selected the five most compelling findings from among the more than 100 noteworthy studies summarized in the article.

Cementless vs Cemented TKA Fixation
—A matched case-control study of 400 primary total knee arthroplasties (TKAs) found that cementless TKAs had a 0.5% rate of aseptic loosening over a mean follow-up of 2.5 years, while cemented TKAs had an aseptic loosening rate of 2.5%.1

TKA Component Size in Obese Patients
—Among 35 revision-TKA patients with a varus collapse of the tibia, 29 weighed >200 lbs. Fehring et al. found that patients with implants at the small end of the range of the manufacturer’s tibial size offering and with >5° of preoperative varus were at increased risk of tibial-component failure.2

Outpatient TKA
—A retrospective multivariate analysis of >4,300 patients who underwent outpatient TKA and >128,900 patients who underwent inpatient TKA found that, within 1 year, those who had outpatient procedures were more likely to experience a tibial and/or femoral component revision due to a noninfectious cause, irrigation and debridement, explantation of the prosthesis, and stiffness requiring manipulation under anesthesia.

Infection Prevention
—In a randomized trial of patients undergoing TKA, one group received 15 mg/kg of systemic intravenous vancomycin, and a second group received intraosseous regional administration of 500 mg vancomycin into the tibia. Mean tissue concentrations of the antibiotic were 34.4 mg/g in the intraosseous group and 6.1 mg/g in the intravenous group, suggesting that intraosseous administration provides a significantly higher tissue concentration of that antibiotic. 3

TKA Anesthesia Protocol
—A retrospective review of 156 consecutive patients who underwent primary TKA found that procedures performed with mepivacaine spinal anesthesia led to fewer episodes of urinary catheterization and shorter mean length of stay compared with procedures performed with bupivacaine spinal anesthesia.4

References

  1. Miller AJ, Stimac JD, Smith LS, Feher AW, Yakkanti MR, Malkani AL. Results of cemented vs cementless primary total knee arthroplasty using the same implant design. J Arthroplasty.2018 Apr;33(4):1089-93. Epub 2017 Dec
  2. Fehring TK, Fehring KA, Anderson LA, Otero JE, Springer BD. Catastrophic varus collapse of the tibia in obese total knee arthroplasty. J Arthroplasty.2017 May;32(5):1625-9. Epub 2017 Jan 30.
  3. Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS Clinical Research Award: intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee arthroplasty: a randomized trial. J Arthroplasty.2018 Jul;33(7S):S13-8. Epub 2018 Mar 15.
  4. Mahan MC, Jildeh TR, Tenbrunsel TN, Davis JJ. Mepivacaine spinal anesthesia facilitates rapid recovery in total knee arthroplasty compared to bupivacaine. J Arthroplasty.2018 Jun;33(6):1699-704. Epub 2018 Jan 16.

What’s New in Musculoskeletal Basic Science 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, Matthew J. Allen, VetMB, PhD, author of the December 5, 2018 Specialty Update on Musculoskeletal Basic Science, focuses on the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.

Gene Editing in Orthopaedics

–Gene-editing tools such as CRISPR-Cas9 have great potential as a means of introducing therapeutic genes into mesenchymal stem cells that can then be targeted to tissues in vivo. These researchers1 reported on genetically modified stem cells that have the potential to differentiate into chondrocytes encoding a natural inhibitor of interleukin-1, providing an opportunity for localized release of immunomodulatory factors.

Managing Orthopaedic Infections

–A novel study2 in which transmission electron microscopy was used to identify viable bacteria deep within the canalicular structure of cortical bone, remote from the site of an infected implant, suggests that effective debridement requires the removal of not just necrotic tissue, but also of adjacent, apparently unaffected bone.

Computational Modeling of Human Movement

–This report3 presented a human musculoskeletal model that provided extremely accurate predictions of ground reaction forces during simulated walking and squatting. As similar models are developed and validated, surgeons will have improved tools for evaluating patients, planning surgery, and making decisions about which procedure/implant is most appropriate for an individual patient.

Sex-Related Differences

–This report4 demonstrated sexually dimorphic regulation of gene-expression profiles in bone marrow osteoprogenitor cells that could partly explain clinical observations in sex differences in peak bone mass, bone remodeling, and immunomodulation.

Biological Enhancement of Ligament Healing

–Among several basic science papers focused on the optimal healing and durable fixation of tendons and ligaments, this notable work5 reported on the translation of bridge-enhanced ligament repair for the anterior cruciate ligament.

References

  1. Brunger JM, Zutshi A, Willard VP, Gersbach CA, Guilak F. CRISPR/Cas9 editing of murine induced pluripotent stem cells for engineering inflammation-resistant tissues. Arthritis Rheumatol.2017 May;69(5):1111-21. Epub 2017 Mar 31.
  2. de Mesy Bentley KL, Trombetta R, Nishitani K, Bello-Irizarry SN, Ninomiya M, Zhang L, Chung HL, McGrath JL, Daiss JL, Awad HA, Kates SL, Schwarz EM. Evidence of Staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis. J Bone Miner Res.2017 May;32(5):985-90. Epub 2017 Jan 26.
  3. Jung Y, Koo YJ, Koo S. Simultaneous estimation of ground reaction force and knee contact force during walking and squatting. Int J Precis Eng Manuf.2017;18(9):1263-8.
  4. Kot A, Zhong ZA, Zhang H, Lay YE, Lane NE, Yao W. Sex dimorphic regulation of osteoprogenitor progesterone in bone stromal cells. J Mol Endocrinol.2017 Nov;59(4):351-63. Epub 2017 Sep 4.
  5. Perrone GS, Proffen BL, Kiapour AM, Sieker JT, Fleming BC, Murray MM. Bench-to-bedside: bridge-enhanced anterior cruciate ligament repair. J Orthop Res.2017 Dec;35(12):2606-12. Epub 2017 Jul 9.

What’s New in Orthopaedic Rehabilitation 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, Nitin Jain, MD, MSPH, a co-author of the November 21, 2018 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the more than 40 noteworthy studies summarized in the article.

Acute Pain Management

–A randomized double-blind study comparing 4 two-way combinations of analgesics (three of which contained an opioid medication)1 in emergency-department patients experiencing acute extremity pain found no significant between-group differences in mean pain scores at 1 and 2 hours after medication administration.

Total Hip Arthroplasty

–A randomized clinical trial of >100 patients who underwent unilateral total hip arthroplasty found no significant differences in functional outcomes between a group that participated after surgery in a self-directed home exercise program and a group that participated in a standardized physical therapy program.

Concussion

–An assessment of brain tissue from 202 American football players2 whose organs were donated for neuropathological evaluation found that 87% had evidence of chronic traumatic encephalopathy (CTE). Analysis of brain tissue from former NFL players in the cohort showed that nearly all had severe CTE.

Rotator Cuff Tears

–A study following the natural progression of full-thickness, asymptomatic, degenerative rotator cuff tears found that patients with fatty muscle degeneration were more likely to experience tear-size progression than those without fatty infiltration.

Low Back Pain

–A study consolidating data from 3 separate randomized trials attempted to evaluate the efficacy of radiofrequency (RF) neurotomy for treating a heterogeneous collection of diagnoses that commonly result in low back pain.3 No significant or clinically important differences were found when the RF procedure was compared with a standardized exercise program. The number needed to treat for all 3 arms of the study ranged from 4 to 8, with a median of 5. Some have called into question the methods of this study, particularly the diagnostic criteria used for patient inclusion and the potential inaccuracy of lumping together heterogeneous diagnoses.

References

  1. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.
  2. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML,Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC,Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017 Jul 25;318(4):360-70.
  3. Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68-81.

What’s New in Shoulder and Elbow Surgery 2018

Shoulder & elbowEvery 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, Robert Tashjian, MD, co-author of the October 17, 2018 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.

Progression of Primary Osteoarthritis
–A study evaluating the relationship between glenoid erosion patterns and rotator cuff muscle fatty infiltration found that fatty infiltration was associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. The authors recommend close observation of patients with B-type glenoids, as the progression of glenoid erosion is more likely in B-type than A-type glenoids.

Perioperative Pain Management
–In a randomized controlled trial of perioperative pain management in patients undergoing primary shoulder arthroplasty, narcotic consumption during the first 24 postoperative hours was similar between a group that received interscalene brachial plexus blockade and a group that received intraoperative soft-tissue infiltration of liposomal bupivacaine. The interscalene group had lower VAS pain scores at 0 and 8 hours postoperatively; both groups had similar VAS pain scores at 16 hours; and the soft-tissue infiltration group had lower pain scores at 24 hours postoperatively.

Rotator Cuff
–In a reevaluation of patients with nonoperatively treated chronic, symptomatic full-thickness rotator cuff tears that had become asymptomatic at 3 months, researchers found that at a minimum of 5 years, 75% of the patients remained asymptomatic.1 The Constant scores in the group that remained asymptomatic were equivalent at 5 years to those who initially underwent surgical repair. While these findings suggest that nonoperative treatment can yield clinical success at 5 years, the authors caution that “individuals with substantial tear progression or the development of atrophy will likely have a worse clinical result.”

–A recent study of the progression of fatty muscle degeneration in asymptomatic shoulders with degenerative full-thickness rotator cuff tears found that larger tears at baseline had greater fatty degeneration, and that tears with fatty degeneration were more likely to enlarge over time. Median time from tear enlargement to fatty degeneration was 1 year. Because the rapid progression of muscle degeneration seems to occur with increasing tear size, such patients should be closely monitored if treated nonoperatively.

Shoulder Instability in Athletes
–An evaluation of outcomes among 73 athletes who had undergone Latarjet procedures found that, after a mean follow-up of 52 months, ASES scores averaged 93. However, only 49% of the athletes returned to their preoperative sport level; 14% decreased their activity level in the same sport; and 12% changed sports altogether. While the Latarjet can help stabilize shoulders in athletes, the likelihood is high that the athlete won’t return to the same level in the same sport after the procedure.

Reference

  1. Boorman RS, More KD, Hollinshead RM, Wiley JP, Mohtadi NG, Lo IKY, Brett KR. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2018 Mar;27(3):444-8.

What’s New in Hip Replacement 2018

Hip_600

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, Mengnai Li, MD, co-author of the September 19, 2018 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 100 studies covered in the Specialty Update.

The Benefits of HXLPE
–A double-blinded study that randomized patients to receive either a conventional polyethylene liner or one made from highly cross-linked polyethylene (HXLPE) found that, after a minimum of 10 years, the HXLPE group had significantly lower wear rates, lower prevalence of osteolysis, and lower revision rates than the conventional-liner group.

Outcomes for Hip Fracture vs OA
–A propensity score-matched cohort analysis of NSQIP data found that total hip arthroplasty (THA) undertaken to treat hip fractures among Medicare beneficiaries was significantly associated with an increased risk of CMS-reportable complications, non-homebound discharge, and readmission, relative to THA undertaken to treat osteoarthritis.1

Infection Risk Factors
–A multicenter retrospective study found that a threshold of 7.7% for hemoglobin A1c was more predictive of periprosthetic joint infection than the commonly used 7%, and the authors suggest that 7.7% should be considered the goal in preoperative patient optimization.2

THA in Patients with RA
–Recently published guidelines from the American College of Rheumatology and AAHKS regarding antirheumatic medication use in patients with rheumatic diseases who are undergoing THA suggest the following:

  • Continuing nonbiologic disease-modifying antirheumatic drugs (DMARDs)
  • Continuing the same daily dose of corticosteroids
  • Withholding biologic agents prior to surgery
  • Planning surgery for the end of the biologic dosing cycle.

All recommendations are conditional due to the low or moderate-quality evidence on which they were based.3

Blood Management
–A double-blinded, randomized trial found that oral tranexamic acid (TXA) provided equivalent reductions in blood loss in the setting of primary THA, at greatly reduced cost, compared with intravenous TXA.

References

  1. Qin CD, Helfrich MM, Fitz DW, Hardt KD, Beal MD, Manning DW. The Lawrence D. Dorr Surgical Techniques & Technologies Award: differences in postoperative outcomes between total hip arthroplasty for fracture vs osteoarthritis. J Arthroplasty. 2017 Sep;32(9S):S3-7. Epub 2017 Feb 6.
  2. Tarabichi M, Shohat N, Kheir MM, Adelani M, Brigati D, Kearns SM, Patel P, Clohisy JC, Higuera CA, Levine BR, Schwarzkopf R, Parvizi J, Jiranek WA. Determining the threshold for HbA1c as a predictor for adverse outcomes after total joint arthroplasty: a multicenter, retrospective study. J Arthroplasty. 2017 Sep;32(9S): S263-7: 267.e1. Epub 2017 May 11.
  3. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, Gewurz- Singer O, Giles JT, Johnson B, Lee S, Mandl LA, Mont MA, Sculco P, Sporer S, Stryker L, Turgunbaev M, Brause B, Chen AF, Gililland J, Goodman M, Hurley-Rosenblatt A, Kirou K, Losina E, MacKenzie R, Michaud K, Mikuls T, Russell L, Sah A, Miller AS, Singh JA, Yates A. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2017 Sep;32(9):2628-38. Epub 2017 Jun 16.

What’s New in Musculoskeletal Infection 2018

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, and his co-authors of the July 18, 2018 Specialty Update on Musculoskeletal Infection, selected the most clinically compelling findings from among the more than 130 studies summarized in the Specialty Update.

CDC Guidelines on Surgical Site Infection (SSI) Prevention

–The most provocative recommendation in the CDC SSI Prevention Guidelines,1 released in 2017, was to encourage administration of parenteral antimicrobial prophylaxis prior to surgery so that a bactericidal concentration is established in the tissue and serum when the incision is made. Postoperatively, the CDC recommended that antimicrobial prophylaxis not be administered in clean and clean-contaminated procedures after incision closure, even if a drain is present.

Treating Periprosthetic Infection

–When performing debridement to treat a periprosthetic joint infection, dilute methylene blue (0.1%) applied to the tissue prior to debridement (with removal of excess dye) may help surgeons visualize devitalized tissue (biofilm) that should be debrided at the time of infection.2,3

Wound Closure

–Two Level-I studies showed that specific wound-closure techniques can improve incisional perfusion. This was seen in the setting of ankle fracture with the Allgower-Donati suture technique4 and in elective total knee arthroplasty with a running subcuticular closure5.

Antimicrobial Prophylaxis

–Two studies reported on the microbiological impact of locally applied vancomycin powder.6,7  For patients who developed infections after surgery despite the application of vancomycin powder, a greater frequency of gram-negative organisms was identified, highlighting the importance of obtaining specimens for culture.

Hand Infections

–Atypical hand infections caused by Mycobacterium tuberculosis, non-tuberculous mycobacterium, and fungi are uncommon, making high-level clinical trials unrealistic.  But these atypical infections are frequent enough that multiple cases are reported, drawing attention to the need for awareness of their clinical presentation,8 even in immunocompetent patients,9 and the need for understanding that cultures should be sent when suspicion is high, even if there is purulence consistent with a typical bacterial infection.10

References

  1. Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-91.
  2. Shaw JD, Miller S, Plourde A, Shaw DL, Wustrack R, Hansen EN. Methylene blue guided debridement as an intraoperative adjunct for the surgical treatment of periprosthetic joint infection. J Arthroplasty. 2017 Dec;32(12):3718-23.
  3. Parry JA, Karau MJ, Kakar S, Hanssen AD, Patel R, Abdel MP. Disclosing agents for the intraoperative identification of biofilms on orthopedic implants. J Arthroplasty. 2017 Aug;32(8):2501-4.
  4. Shannon SF, Houdek MT,Wyles CC, Yuan BJ, CrossWW3rd, Cass JR, Sems SA. Allgower-Donati versus vertical mattress suture technique impact on perfusion in ankle fracture surgery: a randomized clinical trial using intraoperative angiography.  J Orthop Trauma. 2017 Feb;31(2):97-102.
  5. Wyles CC, Jacobson SR, Houdek MT, Larson DR, Taunton MJ, Sim FH, Sierra RJ, Trousdale RT. The Chitranjan Ranawat Award: running subcuticular closure enables the most robust perfusion after TKA: a randomized clinical trial. Clin Orthop Relat Res. 2016 Jan;474(1):47-56.
  6. Adogwa O, Elsamadicy AA, Sergesketter A, Vuong VD, Mehta AI, Vasquez RA, Cheng J, Bagley CA, Karikari IO. Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1200 consecutive surgical cases. J Neurosurg Spine. 2017 Sep;27(3):328-34. Epub 2017 Jun 30.
  7. Chotai S, Wright PW, Hale AT, Jones WA, McGirt MJ, Patt JC, Devin CJ. Does intrawound vancomycin application during spine surgery create vancomycin-resistant organism? Neurosurgery. 2017 May 1;80(5):746-53.
  8. Lopez M, Croley J, Murphy KD. Atypical mycobacterial infections of the upper extremity: becoming more atypical? Hand (N Y). 2017 Mar;12(2):188-92. Epub 2016 Jul.
  9. Sotello D, Garner HW, Heckman MG, Diehl NN, Murray PM, Alvarez S. Nontuberculous mycobacterial infections of the upper extremity: 15-year experience at a tertiary care medical center. J Hand Surg Am. 2017 Dec 6:S0363-5023(16)30908-X. Epub 2017 Dec 6
  10. Kazmers NH, Fryhofer GW, Gittings D, Bozentka DJ, Steinberg DR, Gray BL. Acute deep infections of the upper extremity: the utility of obtaining atypical cultures in the presence of purulence. J Hand Surg Am. 2017 Aug;42(8):663.e1-8. Epub 2017 May 25.

What’s New in Orthopaedic Trauma 2018

Trauma 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, Niloofar Dehghan, MD, co-author of the July 5, 2018 Specialty Update on Orthopaedic Trauma, selected the five most clinically compelling findings from among the 32 studies summarized in the Specialty Update.

Clavicle Fractures
–Findings from a multicenter randomized trial comparing open reduction/internal fixation with nonoperative treatment for acute, displaced, distal-third clavicle fractures1 included the following:

  • No between-group differences in DASH and Constant scores at 1 year post-injury
  • Higher rates of nonunion and malunion in the nonoperative group
  • Similar rates of secondary surgical procedures in the two groups

Despite no significant differences in functional outcomes between the two groups, primary fixation of these fractures reduced the risk of nonunion and malunion and decreased the magnitude of secondary procedures.

Humerus Fractures
–A retrospective cohort study of 84 patients with nonoperatively treated humerus shaft fractures2 showed fracture union in 87% of the cohort at a mean of 18 weeks. However, researchers found that if physical examination at 6 weeks after injury revealed motion at the fracture site, progression to fracture union was unlikely. They concluded that results from clinical examination of fracture motion at 6 weeks could help patients and physicians with shared decision-making regarding the appropriateness of transitioning to surgical fixation

Syndesmotic Ankle Injuries
–A randomized controlled trial compared outcomes between a suture button and 1 quadricortical syndesmotic screw in patients undergoing syndesmosis fixation. After 2 years, patients in the suture button group had higher AOFAS ankle scores, higher Olerud-Molander ankle scores, and a lower rate of tibiofibular widening of ≥2 mm than the syndesmotic screw group. Findings also favored the suture button group in terms of symptomatic recurrent syndesmotic diastasis.

–A similar randomized trial compared suture button fixation with screw fixation using two 3.5-mm cortical screws.3 There were no between-group differences in functional outcomes, but the rates of malreduction and unplanned reoperations were higher in the screw group. The suture button group had greater syndesmosis diastasis and less fibular medialization.

Blood Loss Management
–In a randomized trial comparing transfusion rates among 138 patients who underwent arthroplasty for low-energy femoral neck fractures,4 researchers found no significant differences among those treated with tranexamic acid versus those treated with placebo. However, tranexamic acid reduced the amount transfused by 305 mL. There were no between-group differences in adverse events at 30 and 90 days.

References

  1. Canadian Orthopaedic Trauma Society, Hall J, Dehghan N, Schemitsch EH, Nauth A, Korley R, McCormack R, Guy P, Papp S, McKee MD. Operative vs nonoperative treatment of acute displaced distal clavicle fractures: a multicenter randomized controlled trial. Read at the Orthopaedic Trauma Association 33rd Annual Meeting; 2017 Oct 11-14; Vancouver, Canada. Paper no. 4.
  2. Driesman AS, Fisher N, Karia R, Konda S, Egol KA. Fracture site mobility at 6 weeks after humeral shaft fracture predicts nonunion without surgery. J Orthop Trauma.2017 Dec;31(12):657-62.
  3. Canadian Orthopaedic Trauma Society, Sanders D, Schneider P, Tieszer C, Lawendy AR, Taylor M. Improved reduction of the tibiofibular syndesmosis with TightRope compared to screw fixation: results of a randomized controlled study. Read at the Orthopaedic Trauma Association 33rd Annual Meeting; 2017 Oct 11-14; Vancouver, Canada.
  4. Watts CD, Houdek MT, Sems SA, Cross WW, Pagnano MW. Tranexamic acid safely reduced blood loss in hemi- and total hip arthroplasty for acute femoral neck fracture: a randomized clinical trial. J Orthop Trauma.2017 Jul;31(7):345-51.

What’s New in Spine Surgery 2018, Part II

Spine_Graphic for OBuzz

Previously, 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 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.  In this OrthoBuzz post, Theodore J. Choma, MD, author of the Specialty Update on Spine Surgery, selected his “top five.”

Spondylolisthesis
–A registry study of 765 patients with adult isthmic spondylolisthesis and at least 2 years of post-treatment outcome data found that at 1 year, global-assessment improvements were reported in 54% of patients who underwent uninstrumented posterolateral fusion, 68% of patients who underwent instrumented posterolateral fusion, and 70% of patients who underwent interbody fusion. Although similar patterns were seen in VAS back pain scores and in 2-year data, fusion with instrumentation was associated with a higher risk of reoperation.

Acute Low Back Pain
–In a cost analysis using data from a previously published Level-II study that randomized 220 patients with acute low back pain to early physical therapy or usual (delayed-referral) care, authors concluded that the incremental cost of early PT was $32,058 per quality-adjusted life year and that early PT is therefore cost-effective.1

Metabolic Bone Disease
–A randomized trial of 66 women ≥50 years of age who had osteoporosis and had undergone lumbar interbody arthrodesis found that those who received once-weekly teriparatide for 6 months following surgery demonstrated higher fusion rates than those in the control cohort (69% versus 35%). Once weekly teriparatide may be worth considering to improve fusion rates in this challenging patient population.

Adult Deformity Correction
–To test the hypothesis that performing 3-column osteotomies more caudally in the lumbar spine might improve sagittal malalignment correction, authors analyzed 468 patients from a spine deformity database who underwent 3-column osteotomies.2 The mean resection angle was 25.1° and did not vary by osteotomy level. No variations were found in the amount of sagittal vertical axis or pelvic tilt correction, but lower-level osteotomies were associated with more frequent pseudarthroses and postoperative motor deficits.

Spinal Cord Injury
–Authors directly measured the mean arterial pressure and cerebrospinal fluid pressure in 92 consecutive patients with traumatic spinal cord injury. Using that data to indirectly monitor the patients’ spinal cord perfusion pressure,3 the authors found that patients who experienced more episodes of spinal cord perfusion pressures <50 mm Hg were less likely to manifest objective improvements in spinal cord function.

References

  1. Fritz JM, Kim M, Magel JS, Asche CV. Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976).2017 Mar;42(5):285-90.
  2. Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O,Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?J Neurosurg Spine. 2017 Nov;27(5):560-9. Epub 2017 Sep 8.
  3. Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J,Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. 2017 Oct 17;89(16):1660-7. Epub 2017 Sep 15.

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.