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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

What’s New in Hip Replacement

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

This month, James Ninomiya, MD, MS, lead author of the September 21, 2016 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the nearly 70 studies summarized in the Specialty Update.

Bearing Survivorship

–A meta-analysis found no differences in short- and medium-term implant survivorship among the following three bearing combinations used in THA patients younger than 65 years of age: ceramic on ceramic, ceramic on highly cross-linked polyethylene, and metal on highly cross-linked polyethylene.1

Insight into Aseptic Loosening

–Pathogen-associated molecular patterns (“endotoxins”) on particulate wear debris may be partially responsible for aseptic loosening. An in vitro/in vivo study found that macrophages that did not express the pathogen-associated molecular pattern receptor called TIRAP/Mal had significantly diminished secretion of inflammatory proteins. Patients with a genetic polymorphism suppressing that receptor exhibited decreased osteolysis during in vivo experiments. This suggests that some patients may be genetically more prone to aseptic loosening.

THA in Patients with RA

–A systematic review/meta-analysis of patients who were and were not taking a TNF-α inhibitor for rheumatoid arthritis prior to hip replacement found that those taking the drug had an increased risk of perioperative infection, with an odds ratio of 2.47.2 These results suggest that in order to decrease the risk of perioperative infections, it may be prudent to discontinue these drugs in advance of proposed joint replacement surgery.

Delaying THA for Femoral Head Osteonecrosis

–A systematic review/meta-analysis of patients with femoral head osteonecrosis concluded that injection of autologous bone marrow aspirate containing mesenchymal stem cells during core decompression was superior by a factor of 5 to core decompression alone in preventing collapse of the femoral head and delaying conversion to THA. This information may lead to new treatment paradigms for osteonecrosis.

Preventing Post-THA Dislocations

–A systematic review/meta-analysis that included more than 1,000 patients who underwent THA with a posterior or anterolateral approach found similar dislocation rates among those who were and were not given post-procedure restrictions in motion or activity.4   This suggests that the use of traditional hip precautions may not be necessary, and in fact may impede the rate of recovery following joint replacement surgery.

References

  1. Wyles CC, Jimenez-Almonte JH,  Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, TrousdaleRT. There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.
  2. Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP. Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis. Rheumatology (Oxford). 2016 Mar;55(3):573-82. Epub 2015 Oct 7.
  3. Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV. The role of “cell therapy” in osteonecrosis of the femoral head. A systematic review of the literature and meta-analysis of 7 studies. Acta Orthop. 2016 Feb;87(1):72-8. Epub 2015 Jul 29.
  4. Van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil. 2016 Apr;30(4):329-39. Epub 2015 Mar 31.

What’s New in Musculoskeletal Infection: Update on Biofilms

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, Arvind Nana, MD, co-author of the July 20, 2016 Specialty Update on musculoskeletal infection, selected the three most compelling discoveries from among the more than 100 studies cited in the Specialty Update, which focused on biofilms.

Dr. Nana and his co-authors provide a concise primer on the biology of biofilms, the network of microorganisms that adhere to implant surfaces and form a complex structure surrounded by a self-generated extracellular polymeric matrix. This matrix not only anchors bacteria to orthopaedic implants, but also provides a nearly impenetrable defense mechanism against the host immune system. Staphylococci are the most common biofilm-forming bacteria found in orthopaedics.

Persister Cells in Biofilms

So-called persister cells have an inherent tolerance to antimicrobial agents. Misconceptions about persisters have permeated the literature. The authors provide clarification about persisters:

  • Persister cells CAN be reliably killed when the antimicrobial concentration is high enough. The minimum biofilm eradication concentration (MBEC) is lower when antimicrobial exposure is continuous and prolonged.1
  • Decreasing the number of microorganisms with antimicrobial intervention is NOT good enough. Cure requires the total elimination of all viable microbes.

Biofilm in Orthopaedic Trauma

Biofilm formation in the setting of open fractures is concerning because biofilm can develop on bone and in soft tissues in a matter of hours. The assumption is that appropriate surgical techniques for open fractures, including therapeutic antibiotic administration, can decrease bioburden and provide fracture stability, thus modulating the acute, local inflammatory response and minimizing biofilm formation.2 However, current technology does not enable noninvasive quantification of biofilm activity and presence in a stable open fracture following wound closure.

Biofilm in Total Joint Arthroplasty

Traditionally, prosthesis-related biofilm infections in the US have been treated by a 2-stage exchange arthroplasty. Although biofilm from the implant is removed by extraction of the components, the potential exists for persistence of biofilm in the surrounding soft tissues. Most patients treated for periprosthetic joint infections also receive intravenous antibiotics, but a recent in vitro study demonstrated that administering cefazolin even at increased concentrations still resulted in persistent Staphylococcus biofilm on cobalt-chromium, polymethylmethacrylate, and polyethylene,3 which supports the need for explantation.

There is still room to develop novel treatment methods for eradicating biofilm in periprosthetic joint infections. Future novel treatment methods for eradicating implant biofilm will help minimize the morbidity associated with current accepted periprosthetic joint infection treatment options.

References

  1. Castaneda P, McLaren A, Tavaziva G, Overstreet D. Biofilm antimicrobial susceptibility increases with antimicrobial exposure time. Clin Orthop Relat Res. 2016 Jan 21.
  1. Pfeifer R, Darwiche S, Kohut L, Billiar TR, Pape HC. Cumulative effects of bone and soft tissue injury on systemic inflammation: a pilot study. Clin Orthop Relat Res. 2013 Sep;471(9):2815-21.
  2. Urish KL, DeMuth PW, Kwan BW, Craft DW, Ma D, Haider H, Tuan RS, Wood TK, Davis CM 3rd..Antibiotic-tolerant Staphylococcus aureus biofilm persists on arthroplasty materials. Clin Orthop Relat Res.2016 Feb 1.

What’s New in Orthopaedic Trauma

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, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.

Shoulder

–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1

Wrist

–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2

Tibia

–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3

Ankle

–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4

Managing Thromboembolism

–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.

Wound Care

–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5

–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6

Obesity

–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7


References

  1. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
  2. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
  3. Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
  4. Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
  5. Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
  6. Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
  7. Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.

What’s New in Spine 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, OrthoBuzz asked Theodore Choma, MD and Darrel Brodke, MD, co-authors of the June 15, 2016 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies they cited.

Antifibrinolytics

–A Level-I meta-analysis of 11 RCTs showed that tranexamic acid significantly lowered perioperative blood loss and transfusion requirements during spine surgery, with no associated increased incidence of heart attack or pulmonary embolism.1

Adult Spinal Deformity

–An analysis of prospective registry data from 766 adult patients with spinal deformity found that health-related quality-of-life scores for those patients prior to any intervention were lower than pre-intervention scores for patients with arthritis, chronic lung disease, diabetes, and congestive heart failure. The authors concluded that the global burden of spinal deformity warrants research and health-policy attention comparable to that given to other high-burden conditions.2

Lumbar Spine

–A double-blind RCT of patients presenting to the emergency department with acute nonradicular low back pain found no difference in one-week disability scores among three groups: those given naproxen + cyclobenzaprine; those given naproxen + oxycodone/acetaminophen; and those given naproxen + placebo. The findings led the authors to conclude that adding those drugs to naproxen provides no clinical benefit.3

–A post-hoc analysis of SPORT data focused on patients ≥80 years old with degenerative spondylolisthesis found that operative treatment conferred a significant benefit relative to nonoperative treatment. The researchers found no significant increases in postoperative complication or mortality rates in this patient population compared with younger post-op patients.

Spine Fractures

–A 16- to 22-year follow-up of a previous randomized trial of 47 patients from the 1990s who had been randomized to operative or nonoperative treatment after a stable thoracolumbar burst fractures found that those treated nonoperatively had less pain and better function than those who had been treated operatively.

References

  1. Cheriyan T,Maier SP 2nd., Bianco K, Slobodyanyuk K, Rattenni RN, Lafage V, Schwab FJ, Lonner BS, Errico TJ. Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. Spine J. 2015Apr 1;15(4):752-61. Epub 2015 Jan 21.
  2. Pellisé F, Vila-Casademunt A, Ferrer M, Domingo-Sàbat M, Bagó J, Pérez Grueso FJ, Alanay A, MannionAF, Acaroglu E;European Spine Study Group, ESSG. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015 Jan;24(1):3-11. Epub 2014 Sep 14.
  3. 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.

What’s New in Foot and Ankle 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, OrthoBuzz asked Sheldon Lin, MD and Michael Yeranosian, MD, co-authors of the May 18, 2016 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies they cited.

Ankle Fractures and Syndesmotic Injuries

–A randomized study compared syndesmotic fixation versus no fixation in patients with supination-external rotation (SER) IV-type ankle fractures and positive intraoperative stress tests (persistent widening of the medial clear space). At four years of follow-up researchers found no clinical or radiological differences between the two groups.1

–A randomized single-blinded trial to help determine optimal methods for soft-tissue management after ankle trauma compared standard treatment using ice and elevation with the use of multilayer compression bandages. Researchers found that multilayer compression therapy resulted in faster resolution of edema than cryotherapy.

Total Ankle Arthroplasty

–A prospective cohort study found that patients undergoing total ankle arthroplasty (TAA) had higher preoperative expectation scores than did those undergoing ankle arthrodesis. TAA patients were also more likely than arthrodesis patients to report improved postoperative satisfaction scores. Postoperative expectation and satisfaction scores in both groups were closely linked to postoperative Ankle Osteoarthritis Scale (AOS) scores. The study emphasizes the importance of preoperative patient education.2

Orthobiologics

–A randomized controlled trial looking at union rates in ankle and hindfoot arthrodesis compared the use of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) plus an injectable osteoconductive beta-tricalcium phosphate (β-TCP) collagen matrix to standard autograft.  Complete fusion of all involved joints at 24 weeks occurred in 84% of those treated with the growth factor-matrix combination and in 65% of those treated with autograft (p <0.001).3

Patient-Reported Outcomes Assessment

–The 10-center Orthopaedic Foot & Ankle Outcomes Research (OFAR) Network conducted a three-month trial of collecting preoperative and six-month postoperative patient outcome information using the Patient Reported Outcomes Measurement Information System (PROMIS). Of the 328 patients enrolled, 76% completed the preoperative instruments and 43% completed the six-month postoperative instruments. Despite substantial loss to follow-up, the OFAR Network process enabled easy data aggregation and analysis, suggesting its utility in facilitating multicenter trials.4

References

  1. Kortekangas THJ, Pakarinen HJ, Savola O, Niinimäki J, Lepojärvi S, Ohtonen P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2014 Oct;35(10):988-95. Epub 2014 Jun 24.
  1. Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
  1. Daniels TR, Younger ASE, Penner MJ, Wing KJ, Le ILD, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW. Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int. 2015 Jul;36(7):739-48.Epub 2015 Apr 6.
  1. Hunt KJ, Alexander I, Baumhauer J, Brodsky J, Chiodo C, Daniels T, Davis WH, Deland J, Ellis S, Hung M, Ishikawa SN, Latt LD, Phisitkul P, SooHoo NF, Yang A, Saltzman CL; OFAR (Orthopaedic Foot and Ankle Outcomes Research Network). The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle. Foot Ankle Int. 2014Sep;35(9):847-54.

 

What’s New in Sports Medicine

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

This month, OrthoBuzz asked Warren Dunn, MD, a co-author of the April 20, 2016 Specialty Update on sports medicine, to select the five most clinically compelling findings from among the more than 30 studies cited in the article.

Shoulder

–What happens to asymptomatic rotator cuff tears over time?  According to a long-term prospective study of patients who had an asymptomatic tear in one shoulder and a symptomatic contralateral rotator cuff tear, the asymptomatic tears enlarged in almost one-half of the patients over a median of three years. Those patients who experienced tear enlargement tended to have an onset of new pain and progressive degenerative changes within the supraspinatus and infraspinatus muscles. The authors concluded that many formerly asymptomatic tears will progress to become symptomatic.

–Does tendon repair yield better outcomes than physical therapy (PT) when treating rotator cuff tears? A randomized trial of 103 patients with tears not exceeding 3 cm found that 12 of 51 patients (24%) in the PT group subsequently underwent secondary cuff repair over a 5-year follow-up period. Statistically, patients in the primary repair group had significantly better group-mean improvements on the Constant score, ASES score, and VAS for pain and patient satisfaction than those who underwent secondary repair, but the authors noted that these differences “may be below clinical importance.” Thirty-seven percent of those treated with PT only experienced a >5 mm increase in tear size, which was associated with inferior outcomes.

–Are estimates of Propionibacterium acnes colonization rates in surgical shoulder wounds accurate? A controlled diagnostic study examined P. acnes colonization in 117 open shoulder surgeries that utilized the deltopectoral approach. In 20.5% of the procedures, at least one surgical specimen was positive for P. acnes growth, but 13% of cultures from sterile-sponge control samples also had positive growth. This led the authors to surmise that prior estimates of P. acnes incidence may be higher than actual because of frequent culture contamination. Male sex and preoperative corticosteroid injections were associated with a higher likelihood of bacterial growth.

Knee/ACL

–Most people who undergo ACL reconstruction experience significant improvement in physical quality of life and quality-adjusted life years, but who is more or less likely to benefit? A 2- and 6-year longitudinal analysis of a multicenter cohort found that those who underwent revision, smoked cigarettes, had lateral tibial plateau chondromalacia, or had less education were more likely to score lower on the Physical Component Summary of the Short Form-36. Those who tended to have higher postoperative functional scores were those with higher baseline function, younger age, lower BMI, and either no lateral meniscal treatment or >50% lateral meniscectomy.

Hamstring Injuries

–Hamstring injuries are common among soccer players. A Level I randomized controlled trial among 579 high-level amateur soccer players found that 13 weeks of participation in Nordic hamstring exercises significantly reduced injury incidence and risk for injury compared with a control group over a 1-year period. No differences in injury severity were found.1

Reference

  1. van der Horst N, Smits DW, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015 Jun;43(6):1316-23. Epub 2015 Mar 20.