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What’s New in Orthopaedic Trauma 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries. 

This month, co-author Mai P. Nguyen, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the recently published “What’s New in Orthopaedic Trauma.” 

Proximal Humeral Fracture 

–The DelPhi (Delta prosthesis-PHILOS plate) study, a multicenter, single-blinded, randomized controlled trial (RCT), evaluated the outcomes of reverse shoulder arthroplasty vs open reduction and internal fixation for displaced proximal humeral fractures in elderly patients. The results favored reverse shoulder arthroplasty (mean 2-year Constant-Murley score of 68.0 vs. 54.6 points for the 2 groups, respectively). 

Hip Fracture 

–An RCT comparing hemiarthroplasty with or without cement in elderly patients with a displaced intracapsular fracture of the hip found better results for cemented hemiarthroplasty1. There was a trend toward a higher mortality rate in the uncemented group, and although pain scores and reoperations were similar between the groups, better recovery of mobility was noted for the cemented group. 

Proximal Femoral Fracture 

–Another recent RCT investigated the efficacy of a preoperative fascia iliaca compartment block (FICB) for patients with proximal femoral fractures (neck, intertrochanteric, or subtrochanteric regions)2. Lower morphine consumption (0.4 vs 19.4 mg; p = 0.05) and greater patient-reported satisfaction (31%; p = 0.01) were noted for the FICB cohort. 

Ankle Fracture 

–Among patients treated for unstable, rotational-type ankle fractures, a prospective RCT compared weight-bearing at 2 vs 6 weeks postoperatively3. Early weight-bearing at 2 weeks was associated with higher EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) scores at the 6-week follow-up. No difference, however, was seen at later follow-up time points. 

Recovery After Trauma 

–The impact of trauma recovery services (TRS), which provide education and psychosocial support to patients with trauma and their families, was assessed in a recent study4. A total of 294 patients with operatively treated extremity fractures were prospectively surveyed. Injury, social, and demographic characteristics were studied for a possible association with patient-satisfaction scores. Use of TRS was the greatest predictor of better overall care ratings. 

References 

  1. Parker MJ, Cawley S. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip: a randomized trial of 400 patients. Bone Joint J. 2020 Jan;102-B(1):11-6. 
  2. Thompson J, Long M, Rogers E, Pesso R, Galos D, Dengenis RC, Ruotolo C. Fascia iliaca block decreases hip fracture postoperative opioid consumption: a prospective randomized controlled trial. J Orthop Trauma. 2020 Jan;34(1):49-54. 
  3. Schubert J, Lambers KTA, Kimber C, Denk K, Cho M, Doornberg JN, Jaarsma RL. Effect on overall health status with weightbearing at 2 weeks vs 6 weeks after open reduction and internal fixation of ankle fractures. Foot Ankle Int. 2020 Jun;41(6):658-65. Epub 2020 Mar 6. 
  4. Simske NM, Benedick A, Rascoe AS, Hendrickson SB, Vallier HA. Patient satisfaction is improved with exposure to Trauma Recovery Services. J Am Acad Orthop Surg. 2020 Jul 15;28(14):597-605.

What’s New in Spine Surgery 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries. 

This month, co-author Jacob M. Buchowski, MD, MS summarizes the 5 most compelling findings from the studies highlighted in the recently published “What’s New in Spine Surgery.” 

Degenerative Cervical Myelopathy

–In a multicenter, double-blinded, placebo-controlled, randomized phase-3 trial, investigators found no additional benefit from riluzole use with regard to functional outcome scores among patients who underwent decompression and fusion for cervical myelopathy1. The primary outcome of interest was the change in the modified Japanese Orthopaedic Association (mJOA) score at 6 months. 

Dysphagia After Multilevel ACDF

–A Level-I double-blinded randomized controlled trial demonstrated a significant decrease in the severity of dysphagia after multilevel anterior cervical discectomy and fusion (ACDF) among patients who received local intraoperative corticosteroids (56 in the treatment group vs 53 in the control group)2. 

Preop. Epidural Steroid Injection and Postop. Infection 

–A retrospective study of patients who underwent lumbar spine surgical procedures for radiculopathy and/or spinal stenosis3 found that: 

  • In the decompression group, there was no significant difference in the postoperative infection rate between those who had a preoperative epidural steroid injection (2,957 of 9,903) and those who did not.  
  • Among those who underwent fusion, there was a significantly higher rate of infection (2.68%) for those who had preoperative epidural steroid injection (1,383 of 5,108) vs those who did not (1.69%).  
  • In the fusion group, there was a significantly higher rate of infection for those who had a steroid injection within 30 days or >90 days preoperatively, but patients with injection between 30 and 90 days preoperatively had no increased risk of postoperative infection. 

Adolescent Idiopathic Scoliosis (AIS)

–In a Level-IV study, investigators examined the relationship between thoracic morphology and pulmonary function in patients with AIS (mean age, 15.6 years)4. They found a strong positive correlation between the costophrenic angle distance and forced vital capacity, FEV1, vital capacity, and total lung capacity, suggesting that the costophrenic angle distance can be used to assess pulmonary function outcome. Their findings also suggest that an apical vertebral deviation ratio of >0.2 is associated with moderate to severe impairment of lung function. 

Early-Onset Scoliosis (EOS) 

–In a cross-sectional study of prospectively enrolled patients across multiple centers, investigators examined the influence of the classification of EOS etiology, radiographic parameters, and medical comorbidities on the Early Onset Scoliosis Questionnaire (EOSQ), a measure of health-related quality of life. Scores were lower in many EOSQ domains for patients with neuromuscular and syndromic etiologies. The total and subdomain scores were similar between patients with congenital and idiopathic EOS.  

References 

  1. Fehlings MG, Badhiwala JH, Ahn H, Farhadi HF, Shaffrey CI, Nassr A, Mummaneni P, Arnold PM, Jacobs WB, Riew KD, Kelly M, Brodke DS, Vaccaro AR, Hilibrand AS, Wilson J, Harrop JS, Yoon ST, Kim KD, Fourney DR, Santaguida C, Massicotte EM, Kopjar B. Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial. Lancet Neurol. 2021 Feb;20(2):98-106. Epub 2020 Dec 22. 
  2. Kim HJ, Alluri R, Stein D, Lebl D, Huang R, Lafage R, Bennett T, Lafage V, Albert T. Effect of topical steroid on swallowing following ACDF: results of a prospective double-blind randomized control trial. Spine (Phila Pa 1976). 2021 Apr 1;46(7):413-20.  
  3. Kreitz TM, Mangan J, Schroeder GD, Kepler CK, Kurd MF, Radcliff KE, Woods BI, Rihn JA, Anderson DG, Vaccaro AR, Hilibrand AS. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine (Phila Pa 1976). 2021 Feb 1;46(3):E197-202. 
  4. Deng Z, Luo M, Zhou Q, Yang X, Liu L, Song Y. Relationship between pulmonary function and thoracic morphology in adolescent idiopathic scoliosis: a new index, the “apical vertebra deviation ratio”, as a predictive factor for pulmonary function impairment. Spine (Phila Pa 1976). 2021 Jan 15;46(2):87-94. 

 

What’s New in Foot and Ankle Surgery 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, co-author Timothy R. Daniels, MD, FRCSC summarizes the 5 most compelling findings from the >80 studies highlighted in the recently published “What’s New in Foot and Ankle Surgery.”

Telemedicine 

–With virtual foot and ankle examinations become more widespread during the COVID-19 pandemic, a recent paper on telehealth consultations offers guidance on preparing patients for the appointment as well as examination instructions that can be read by clinicians to patients and a checklist for medical record documentation1.

Ankle Reconstruction 

–Evaluating trends in foot and ankle surgery in Germany over the past decade, 1 study found that the volume of foot and ankle operations increased 39.5%, while the population increased 0.9%2. The volume of first metatarsophalangeal joint (MTPJ) arthrodesis and ankle arthrodesis rose 77% and 31%, respectively, whereas first MTPJ arthroplasty and total ankle replacement declined 48% and 39%.

Total Ankle Replacement 

– In a prospective series of total ankle replacement procedures in which a standard anterior approach or an extensile anteromedial surgical approach was used in patients at higher risk for wound complications, 17 (2.6%) of 660 patients had major and 39 (5.9%) had minor wound-healing issues3. All major wound complications occurred in the anterior-approach group.

Morton Neuroma 

–A recent study assessed the utility of preoperative imaging and intraoperative histopathology in Morton neuroma4. Among 313 suspected neuromas operatively resected during the 10-year study period, Morton neuroma was confirmed in 309 (98.7%) on histopathologic examination. The postoperative treatment course was not altered for any patient on the basis of the pathology report, challenging the cost and utility of histopathologic evaluation of resected neuromas.

Patient-Reported Outcomes 

–Another recent study investigated the question of whether sociodemographic factors impact PROMIS scores meeting the Patient-Acceptable Symptom State (PASS) among foot and ankle patients. The authors found that patients ≥65 years of age accepted more functional limitation than younger patients, patients in the lowest income brackets reported more severe functional limitations as satisfactory compared with patients in the highest income brackets, and patients in the lowest income bracket sought surgical care later than those in the highest income bracket5.

References 

  1. Eble SK, Hansen OB, Ellis SJ, Drakos MC. The virtual foot and ankle physical examination. Foot Ankle Int. 2020 Aug;41(8):1017-26. Epub 2020 Jul 8.
  2. Milstrey A, Domnick C, Garcia P, Raschke MJ, Evers J, Ochman S. Trends in arthrodeses and total joint replacements in foot and ankle surgery in Germany during the past decade-back to the fusion? Foot Ankle Surg. 2020 May 26 [Epub ahead of print].
  3. Halai MM, Pinsker E, Daniels TR. Effect of novel anteromedial approach on wound complications following ankle arthroplasty. Foot Ankle Int. 2020 Oct;41(10):1198-205. Epub 2020 Jul 18.
  4. Raouf T, Rogero R, McDonald E, Fuchs D, Shakked RJ, Winters BS, Daniel JN, Pedowitz DI, Raikin SM. Value of preoperative imaging and intraoperative histopathology in Morton’s neuroma. Foot Ankle Int. 2019 Sep;40(9):1032-6. Epub 2019 May 29.
  5. Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do patient sociodemographic factors impact the PROMIS scores meeting the patient-acceptable symptom state at the initial point of care in orthopaedic foot and ankle patients? Clin Orthop Relat Res. 2019 Nov;477(11):2555-65.

What’s New in Sports Medicine 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz Guest Editorial summaries.

This month, co-author Rachel M. Frank, MD summarizes the 5 most compelling findings from the >30 studies highlighted in the April 21, 2021 “What’s New in Sports Medicine.”

Anterior Cruciate Ligament (ACL)

–Two-year results from the STABILITY randomized controlled trial (RCT)1 comparing single-bundle, hamstring-autograft ACL reconstruction with or without lateral extra-articular tenodesis demonstrated a

4% graft failure in the tenodesis group versus 11% in the non-tenodesis group. Both groups had similar levels of sports activity at 2 years.

Meniscus

–A matched cohort comparison of 45 posterior medial meniscal root tears2 treated either nonoperatively, with partial meniscectomy, or with root repair found the following at a mean of 74 months:

  • No significant between-group differences in patient-reported outcomes (IKDC and Tegner scores)
  • Progression to arthroplasty in 60% of those who underwent partial meniscectomy, 27% of those treated nonoperatively, and 0% of those who underwent root repair
  • Less arthritic progression on radiographs in the root-repair group relative to the other 2 groups

Rotator Cuff

A multicenter Level-II study compared 96 patients with a rotator cuff tear who underwent nonoperative treatment with 73 similar patients who underwent a surgical procedure. At approximately 3 months, patients in the nonoperative group had significantly better outcomes, but after 1 to 2 years, surgical patients did better in terms of ASES and SPADI scores.

Hip Preservation

–A meta-analysis of 3 RCTs (n=650 patients)3 comparing physical therapy with hip arthroscopy for treating femoroacetabular impingement found the following:

  • Greater improvement in the arthroscopy group (as measured with the International Hip Outcome Tool-33) at 10 months
  • No between-group differences in 1 of the 3 RCTs at 1 or 2 years when the Hip Outcome Score-ADL and -Sports scales were used

The authors concluded that “hip arthroscopy had significantly superior short-term outcomes.”

Long Head of the Biceps Tendon

–A prospective RCT4 compared biceps tenodesis with biceps tenotomy in >100 patients with pathology of the long head of the biceps tendon. At the 2-year follow-up, the authors found no between-group differences in cramping, elbow flexion strength, or supination strength. The only significant difference was the incidence of a cosmetic Popeye deformity, which was associated with a 3.5 times higher risk after tenotomy.

References

  1. Getgood AMJ, et al. for the STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med.2020 Feb;48(2):285-97. Epub 2020 Jan 15.
  2. Bernard CD, Kennedy NI, Tagliero AJ, Camp CL, Saris DBF, Levy BA, Stuart MJ, Krych AJ. Medial meniscus posterior root tear treatment: a matched cohort comparison of nonoperative management, partial meniscectomy, and repair. Am J Sports Med.2020 Jan;48(1):128-32. Epub 2019 Nov 25.
  3. Dwyer T, Whelan D, Shah PS, Ajrawat P, Hoit G, Chahal J. Operative versus nonoperative treatment of femoroacetabular impingement syndrome: a meta-analysis of short-term outcomes. 2020 Jan;36(1):263-73.
  4. MacDonald P, Verhulst F, McRae S, Old J, Stranges G, Dubberley J, Mascarenhas R, Koenig J, Leiter J, Nassar M, Lapner P. Biceps tenodesis versus tenotomy in the treatment of lesions of the long head of the biceps tendon in patients undergoing arthroscopic shoulder surgery: a prospective double-blinded randomized controlled trial. Am J Sports Med.2020 May;48(6):1439-49. Epub 2020 Mar 30.

What’s New in Hand and Wrist Surgery 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 specialty areas. Click here for a collection of all such OrthoBuzz Guest Editorial summaries.

This month, author Christopher J. Dy, MD, MPH summarizes the 5 most compelling findings from the 40 studies highlighted in the most recent What’s New in Hand and Wrist Surgery.”

Carpal Tunnel Syndrome

–Corticosteroid injection is one modality for managing carpal tunnel syndrome, and a recent study examined the accuracy of needle placement1. Of 756 simulated injections, correct placement was noted for 572 (76%). The needle was placed in the median nerve 66 times (8.7%), and the carpal tunnel was missed 118 times (15.6%). As noted by the study authors, “safety of carpal tunnel injection remains an important concern.”

Cubital Tunnel Syndrome

–One recent study evaluating patient-reported outcomes of in situ decompression for cubital tunnel syndrome found that 66 (86%) of 77 patients were satisfied2. All of the patients who were not satisfied had preoperative weakness of the muscles innervated by the ulnar nerve.

Distal Radial Fracture

–A retrospective radiographic analysis of 273 uninjured adult distal radii found that the volar cortical angle (VCA) ranged from 23° to 43° (mean, 32°)3. With most volar locking plates having a fixed angle of 18° to 30°, there is a strong possibility of a mismatch between the patient’s VCA and the implant. If the patient’s VCA exceeds the implant’s fixed angle, undercorrection of sagittal tilt may result if the plate is used to guide reduction in treating a distal radial fracture.

Dupuytren Contracture

–A recent report presented a single surgeon’s experience over an 11-year time frame with 3 common treatments of Dupuytren contracture4. The rates of reintervention after needle aponeurotomy were 24% at 2 years and 61% at 5 years; after collagenase injection at the same time points, 41% and 55%; and after surgical fasciectomy, 4% at both 2 and 5 years. When factoring in cost, needle aponeurotomy appeared to be a high-value intervention.

Scapholunate Dissociation

–Among 203 patients who underwent  3-ligament tenodesis for scapholunate injury, improvement in patient-reported outcomes at 1 year was noted for 79%, but 10% had no change, and 11% had worse patient-reported outcomes5. Indications for 3-ligament tenodesis may need further clarification.

References

  1. Green DP, MacKay BJ, Seiler SJ, Fry MT. Accuracy of carpal tunnel injection: a prospective evaluation of 756 patients. Hand (N Y). 2020 Jan;15(1):54-8. Epub 2018 Jul 13.
  2. Yeoman TFM, Stirling PHC, Lowdon A, Jenkins PJ, McEachan JE. Patient-reported outcomes after in situ cubital tunnel decompression: a report in 77 patients. J Hand Surg EurVol. Vol 2020 Jan;45(1):51-5. Epub 2019 Oct 30.
  3. Gandhi RA, Hesketh PJ, Bannister ER, Sebro R, Mehta S. Age-related variations in volar cortical angle of the distal radius. Hand (N Y). 2020 Jul;15(4):573-7. Epub 2018 Dec 31.
  4. Leafblad ND, Wagner E, Wanderman NR, Anderson GR, Visscher SL, Maradit Kremers H, Larson DR, Rizzo M. Outcomes and direct costs of needle aponeurotomy, collagenase injection, and fasciectomy in the treatment of Dupuytren contracture. J Hand Surg Am. 2019 Nov;44(11):919-27. Epub 2019 Sep 17.
  5. Blackburn J, van der Oest MJW, Poelstra R, Selles RW, Chen NC, Feitz R; Hand-Wrist Study Group. Three-ligament tenodesis for chronic scapholunate injuries: short-term outcomes in 203 patients. J Hand Surg EurVol. Vol 2020 May;45(4):383-8. Epub 2019 Nov 11.

 

What’s New in Pediatric Orthopaedics 2021

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 14 specialty areas. Click here for a collection of all such OrthoBuzz Guest Editorial summaries.

This month, co-author Lindsay M. Andras, MD summarizes the 5 most compelling findings from the >80 studies highlighted in the most recentWhat’s New in Pediatric Orthopaedics.”

Anterior Vertebral Body Tethering vs Spinal Fusion

–Motion-sparing approaches to scoliosis treatment are attracting increased interest. An informative retrospective study compared 2 to 5-year outcomes of anterior vertebral body tethering (AVBT, 23 patients) and posterior spinal fusion (26 patients) in the treatment of adolescent idiopathic scoliosis. Curve correction was significantly better in the posterior fusion group (mean curve magnitude of 16° vs 33° in the AVBT group). Posterior fusion also demonstrated a revision rate of 0%, while a revision rate of 39% was found for AVBT (9 of 23), with 12 patients (52%) showing evidence of tether breakage.

Antibiotic Regimens for Osteoarticular Infection

–While osteomyelitis is often treated with a 4 to 6-week course of intravenous (IV) antibiotics, intriguing results were reported in a study examining the data of 74 patients before and after the initiation of early transition to oral antibiotics for osteoarticular infection1. In the early transition group, which received IV antibiotics for a median of 7 days, no return ED visits or readmissions were reported. Of note, this approach also appeared to stave off complications related to the peripherally inserted central catheters, which necessitated a return to the ED for 16% of the patients who received the longer course of IV antibiotics.

Developmental Dysplasia of the Hips

–What is the long-term likelihood of total hip arthroplasty (THA) when closed reduction or open reduction and Salter innominate osteotomy is used for the treatment of developmental dysplasia of the hips (DDH) in children after walking age? A comparative analysis of hip survival at 45 years showed that both open and closed reduction “provided substantial benefit relative to the natural history of DDH,” but THA is the expected outcome in middle adulthood, particularly for bilateral hips managed with closed reduction after the age of 18 months.

Legg-Calvé-Perthes Disease

–A case-series report noted “predictable radiographic healing and marked clinical improvement” after open reduction and surgical fixation (ORIF) of symptomatic osteochondritis dissecans lesions seen as sequelae to Legg-Calvé-Perthes disease2. Mean follow-up was 4.6 years.

Pediatric Syndactyly Reconstruction

–Synthetic dermal substitute shows merit as an alternative to skin grafting in syndactyly reconstruction, as found in a recent study3. Of 21 webs, normal vascularity was noted in 20, normal pigmentation in 17, normal skin pliability in 13, and flat scar height in 15, with no complications observed. Of note, a small sheet of synthetic dermal substitute costs approximately $350.

References

  1. Islam S, Biary N, Wrotniak B. Favorable outcomes with early transition to oral antibiotics for pediatric osteoarticular infections. Clin Pediatr (Phila). 2019 Jun;58(6):696-9. Epub 2019 Feb 8.
  2. Lamplot JD, Schoenecker PL, Pascual-Garrido C, Nepple JJ, Clohisy JC. Open reduction and internal fixation for the treatment of symptomatic osteochondritis dissecans of the femoral head in patients with sequelae of Legg-Calvé-Perthes disease. J Pediatr Orthop. 2020 Mar;40(3):120-8.
  3. Wall LB, Velicki K, Roberts S, Goldfarb CA. Outcomes of pediatric syndactyly repair using synthetic dermal substitute. J Hand Surg Am. 2020 Aug;45(8):773.e1-6. Epub 2020 Feb 13.

What’s New in Adult Reconstructive Knee Surgery 2021

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

This month, author Michael J. Taunton, MD summarizes the 5 most compelling findings from the 130 studies highlighted in the January 20, 2021 “What’s New in Adult Reconstructive Knee Surgery.”

Waiting for a Knee Replacement
–Patient wait times for joint arthroplasty, exacerbated in many places by the COVID-19 pandemic, continue to increase. As measured by the EQ-5D, the health among 12% of 2,168 patients awaiting total knee arthroplasty (TKA) in a recent cross-sectional analysis was rated as “worse than death.”1 Joint-specific function and various comorbidities were associated with these findings.

UKA vs TKA
–The multicenter randomized TOPKAT trial2 compared unicompartmental knee arthroplasty (UKA) with TKA for treating medial compartment osteoarthritis. At the 5-year follow-up, there was no between-group difference in Oxford knee scores, but UKA was more cost-effective and provided an additional 0.24 quality-adjusted life year.

Perioperative Patient Optimization
–An observational study analyzing >1,000 total joint arthroplasties3 found that implementing a “perioperative orthopaedic surgical home”—a surgeon-led screening and optimization initiative targeting 8 common modifiable comorbidities—resulted in a 1.6% 30-day readmission rate (versus 5.3% among patients not involved in the initiative).

Pain Management and Opioids
–A randomized controlled trial of >300 patients undergoing primary total knee or hip arthroplasty4 demonstrated that reducing the number of 5-mg oxycodone pills prescribed at discharge from 90 to 30 resulted in the following findings 30 days postoperatively:

  • Similar between-group pain scores
  • No between-group differences in patient-reported outcomes
  • Significant reductions in unused opioid pills and in pain pills taken in the 30-pill group

Periprosthetic Joint Infection
–Patients undergoing primary TKA who had a history of periprosthetic joint infection (PJI) in another joint had a significantly higher risk of PJI after the primary TKA, compared with the risk among a matched cohort with no history of PJI.5

References

  1. Scott CEH, MacDonald DJ, Howie CR. ‘Worse than death’ and waiting for a joint arthroplasty. Bone Joint J.2019 Aug;101-B(8):941-50.
  2. Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK; TOPKAT Study Group. The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. 2019 Aug 31;394(10200):746-56. Epub 2019 Jul 17.
  3. Kim KY, Anoushiravani AA, Chen KK, Li R, Bosco JA, Slover JD, Iorio R. Perioperative orthopedic surgical home: optimizing total joint arthroplasty candidates and preventing readmission. J Arthroplasty.2019 Jul;34(7S):S91-6. Epub 2019 Jan 18.
  4. Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, Gerlinger TL, Buvanendran A, Della Valle CJ. The James A. Rand Young Investigator’s Award: large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplasty.2019 Jul;34(7S):S4-10. Epub 2019 Feb 4.
  5. Chalmers BP, Weston JT, Osmon DR, Hanssen AD, Berry DJ, Abdel MP. Prior hip or knee prosthetic joint infection in another joint increases risk three-fold of prosthetic joint infection after primary total knee arthroplasty: a matched control study. Bone Joint J.2019 Jul;101-B(7_Supple_C):91-7.

What’s New in Musculoskeletal Tumor Surgery 2020

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

This month, author Peter S. Rose, MD summarized the 5 most compelling findings from the 40 studies highlighted in the December 16, 2020 “What’s New in Musculoskeletal Tumor Surgery.”

Primary Bone Tumors
–A retrospective analysis of data from the Euro-EWING99 trial1 is probably the most thorough examination to date of local tumor-control options in Ewing’s sarcoma of the pelvis–a difficult and controversial condition. The authors conclude with a recommendation for aggressive surgery and radiation in many patients, which goes beyond what most North American centers provide.

Metastatic Tumors
–Anderson et al. validate a fracture-risk calculating app2 that provides immediate clinical guidance on the risk of fracture and the role for surgery in patients with skeletal metastases. It is an early example of applying digital technology to provide real-time, individualized clinical guidance.

Phantom Limb Pain
–Alexander et al. provide an excellent early report of a new surgical technique3 (targeted muscle reinnervation) and a focused rehabilitation protocol to decrease phantom limb pain and maximize function after oncologic amputations.

Soft-Tissue Sarcomas
–After analyzing >1,600 patients treated for a soft-tissue sarcoma, Bedi et al. put forth a nomogram4 to predict postoperative wound complications, the single most frequent surgical complication in this population. The finding that BMI, tumor location, and timing of radiation are associated with the risk of wound complications is clinically relevant to all surgeons who treat these patients.

Carcinogenesis from Radiation Exposure
–This thought-provoking study predicted a lifetime fatal cancer risk of 3.5% from medical imaging studies used in the care of polytrauma patients. While the study focused on trauma patients rather than oncology patients, the striking results may have implications for how we use CT imaging to follow tumor patients as well.

References

  1. Andreou D, Ranft A, Gosheger G, Timmermann B, Ladenstein R, Hartmann W, Bauer S, Baumhoer D, van den Berg H, Dijkstra PDS, Dürr HR, Gelderblom H, Hardes J, Hjorth L, Kreyer J, Kruseova J, Leithner A, Scobioala S, Streitbürger A, Tunn PU, Wardelmann E, Windhager R, Jürgens H, Dirksen U; GPOH-Euro-EWING99 Consortium. Which factors are associated with local control and survival of patients with localized pelvic Ewing’s sarcoma? A retrospective analysis of data from the Euro-EWING99 trial. Clin Orthop Relat Res.2020 Feb;478(2):290-302.
  2. Anderson AB, Wedin R, Fabbri N, Boland P, Healey J, Forsberg JA. External validation of PATHFx version 3.0 in patients treated surgically and nonsurgically for symptomatic skeletal metastases. Clin Orthop Relat Res.2020 Apr;478(4):808-18.
  3. Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: early experience of a novel institutional protocol. J Surg Oncol.2019 Sep;120(3):348-58. Epub 2019 Jun 13.
  4. Bedi M, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Cardona K, King DM. Is a nomogram able to predict postoperative wound complications in localized soft-tissue sarcomas of the extremity? Clin Orthop Relat Res.2020 Mar;478(3):550-9.

What’s New in Musculoskeletal Basic Science 2020

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

This month, co-author Philipp Leucht, MD selected the most compelling findings from the 15 studies summarized in the December 2, 2020 “What’s New in Musculoskeletal Basic Science.”

Spine: Annulus Fibrosus Findings
The relatively high prevalence of repeat discectomies has caused researchers to focus on characteristics of the annulus fibrosus, the healing of which often remains incomplete after disc herniation.

–Knowing that the neonatal annulus fibrosus shows regenerative capacity, researchers recently identified Scleraxis-lineage cells as the main contributors to those regenerative properties.1 They discovered that the neonatal cellular programming that results in complete functional restoration of the annulus fibrosus is completely absent in the adult annulus fibrosus after injury. Knowledge of this regenerative mechanism could help scientists develop new treatments for annulus fibrosus regeneration in adults.

–Related research demonstrated that the residual strain of the healthy nucleus pulposus generates pre-strain in the outer annulus fibrosus, and that the loss of residual strain, as seen in disc herniation, results in short-term apoptosis and the emergence of a fibrotic cell phenotype in the annulus fibrosus.2 Blocking cell contractility pathways may therefore offer a viable target to prevent post-injury fibrosis.

Spine: Somitogenesis
–The somitogenesis process in vertebrate development is believed to be controlled by an oscillating genetic “clock.” Researchers developed an in vitro modeling system to recapitulate the human segmentation clock,3 determining that the clock causes a new somite to be formed every 5 hours. This model allowed investigators to assess the function of mutations involved in segmentation defects such as congenital spondylocostal dysostosis. This easily manipulated model could provide the framework for discoveries of the gene oscillations and molecular underpinnings in both normal and abnormal vertebral development.

Osteoarthritis
–Transforming growth factor beta (TGF-β) signaling has been revealing in studying osteoarthritis. Researchers found that mice lacking  in Prx1 osteochondral progenitors during development showed joint developmental defects.4 They further found that both postnatal ablation of Tgfbr2 in osteochondral progenitors and pharmacological inhibition of TGF-β receptor 2 led to an osteoarthritis phenotype with accompanied upregulation of the receptor antagonist IL-36α. They then discovered that an IL-36Ra intra-articular injection attenuates osteoarthritis progression in both Tgfbr2-deletion and posttraumatic arthritis models, confirming the IL-36 family as a viable target in fighting osteoarthritis.

Bone Regeneration
–Skeletal stem and progenitor cells migrate to sites of damage after an injury to participate in the repair process. Researchers recently discovered that the quiescent CXCL12-expressing perisinusoidal bone marrow stromal cells also participate in the repair process5 by converting into a skeletal stem-cell-like state after injury. These CCXL12-positive cells are highly malleable and long-living and thus represent an ideal source for bone tissue regeneration.

References

  1. Torre OM, Mroz V, Benitez ARM, Huang AH, Iatridis JC. Neonatal annulus fibrosus regeneration occurs via recruitment and proliferation of Scleraxis-lineage cells. NPJ Regen Med.2019 Dec 20;4:23.
  2. Bonnevie ED, Gullbrand SE, Ashinsky BG, Tsinman TK, Elliott DM, Chao PG, Smith HE, Mauck RL. Aberrant mechanosensing in injured intervertebral discs as a result of boundary-constraint disruption and residual-strain loss. Nat Biomed Eng.2019 Dec;3(12):998-1008. Epub 2019 Oct 14.
  3. Matsuda M, Yamanaka Y, Uemura M, Osawa M, Saito MK, Nagahashi A, Nishio M, Guo L, Ikegawa S, Sakurai S, Kihara S, Maurissen TL, Nakamura M, Matsumoto T, Yoshitomi H, Ikeya M, Kawakami N, Yamamoto T, Woltjen K, Ebisuya M, Toguchida J, Alev C. Recapitulating the human segmentation clock with pluripotent stem cells. 2020 Apr;580(7801):124-9. Epub 2020 Apr 1.
  4. Li T, Chubinskaya S, Esposito A, Jin X, Tagliafierro L, Loeser R, Hakimiyan AA, Longobardi L, Ozkan H, Spagnoli A. TGF-β type 2 receptor-mediated modulation of the IL-36 family can be therapeutically targeted in osteoarthritis. Sci Transl Med.2019 May 8;11(491):eaan2585.
  5. Matsushita Y, Nagata M, Kozloff KM, Welch JD, Mizuhashi K, Tokavanich N, Hallett SA, Link DC, Nagasawa T, Ono W, Ono N. A Wnt-mediated transformation of the bone marrow stromal cell identity orchestrates skeletal regeneration. Nat Commun.2020 Jan 16;11(1):332.

What’s New in Orthopaedic Rehabilitation 2020

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

This month, co-author Nitin B. Jain, MD selected the most clinically compelling findings from the >30 studies summarized in the November 18, 2020 “What’s New in Orthopaedic Rehabilitation.”

Hip Fracture
–A retrospective cohort study of >43,000 patients with hip fracture and dementia1 found that more frequent, earlier, and larger amounts of postoperative, in-hospital rehabilitation were associated with better recovery in activities of daily living after discharge.

Rotator Cuff
–A cohort study used propensity-score techniques to compare surgical treatment with nonoperative treatment in 127 patients with symptomatic rotator cuff tears.2 At the 18-month follow-up, patients who underwent operative treatment had significantly better shoulder pain and function outcomes than those who underwent nonoperative treatment.

Anterior Cruciate Ligament (ACL)
–A large prospective multicenter study investigating how rehabilitation factors affect the risk of revision ACL procedures after primary reconstruction yielded good news and bad news about the use of an ACL derotational brace for return to activity. Good: Those using the brace had much-improved KOOS scores at 2 years. Bad: Use of the brace doubled the odds of requiring another surgery within 2 years.

Total Knee Arthroplasty (TKA)
–A randomized controlled trial (RCT) of >300 patients who underwent TKA compared traditional in-home or at-clinic rehabilitation with virtual rehabilitation. The 3 main findings after 12 weeks were as follows:

  • The virtual rehab group had a significantly lower median cost.
  • Virtual rehab was not inferior based on KOOS assessments.
  • There were fewer rehospitalizations in the virtual-rehab group.

Orthobiologics
–An RCT compared the efficacy of an ultrasound-guided injection of leukocyte-rich platelet-rich plasma (PRP), leukocyte-poor PRP, and a control saline injection to treat patellar tendinopathy.3 At the 1-year follow-up, neither PRP formulation was found to be more efficacious than the control injection.

References

  1. Uda K, Matsui H, Fushimi K, Yasunaga H. Intensive in-hospital rehabilitation after hip fracture surgery and activities of daily living in patients with dementia: retrospective analysis of a nationwide inpatient database. Arch Phys Med Rehabil.2019 Dec;100(12):2301-7.
  2. Jain NB, Ayers GD, Fan R, Kuhn JE, Warner JJP, Baumgarten KM, Matzkin E, Higgins LD. Comparative effectiveness of operative versus nonoperative treatment for rotator cuff tears: a propensity score analysis from the ROW cohort. Am J Sports Med.2019 Nov;47(13):3065-72. Epub 2019 Sep 13.
  3. Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline.