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What’s New in Adult Reconstructive Knee 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 OrthoBuzz summaries of these “What’s New” articles. This month, author Michael J. Taunton, MD selected the 5 most clinically compelling findings from the more than 130 studies summarized in the January 15, 2020 “What’s New in Adult Reconstructive Knee Surgery.

Unicompartmental Knee Arthroplasty (UKA)
—A prospective cohort study of 1,000 Oxford cementless UKAs indicated by standard Kozinn and Scott criteria found that revision-free survivorship at 10 years was 97%. Progression of lateral osteoarthritis and dislocation of the bearing were the most common reasons for revision.1

Pain Management
—Authors of a double-blinded, prospective, randomized study assigned 60 primary total knee arthroplasty (TKA) patients to receive either a continuous adductor canal block or a single-injection adductor canal block with adjuvant agents. They found no between-group differences in pain scores up to 42 hours postoperatively.2

Post-TKA Physical Therapy (PT)
—A prospective, randomized, noninferiority trial demonstrated that 290 post-TKA patients who were randomized to either outpatient PT, unsupervised web-based PT at home, or unsupervised printed-instruction-based PT at home had no difference in knee range of motion or in patient-reported outcomes at 4 to 6 weeks or 6 months postoperatively.3

Infection Prevention
—In a retrospective review of 29,695 total joint arthroplasties, preoperative penicillin allergy testing led to a 1.19% higher rate of infection-free survival at 10 years, principally by allowing more routine use of the prophylactic antibiotic cefazolin.4

Revision TKA
—A retrospective case series found that patients undergoing revision TKA at an age of < 50 years had a survivorship free of re-revision of 66% at 10 years. Regardless of the reason for revision, this population also had a higher risk of mortality than the general population at 10 years.5

References

  1. Campi S, Pandit H, Hooper G, Snell D, Jenkins C, Dodd CAF, et al. Ten-year survival and seven-year functional results of cementless Oxford unicompartmental knee replacement: A prospective consecutive series of our first 1000 cases. Knee. 2018 Dec;25(6):1231-7. Epub 2018/08/29.
  2. Turner JD, Dobson SW, Henshaw DS, Edwards CJ, Weller RS, Reynolds JW, et al. Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial. J Arthroplasty. 2018 Oct;33(10):3160-6 e1. Epub 2018/06/16.
  3. Fleischman AN, Crizer MP, Tarabichi M, Smith S, Rothman RH, Lonner JH, et al. 2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial. Clin Orthop Relat Res. 2019 Jan;477(1):60-9. Epub 2019/02/23.
  4. Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, et al. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J. 2019 Jun;101-B(6_Supple_B):9-15. Epub 2019/05/31.
  5. Chalmers BP, Pallante GD, Sierra RJ, Lewallen DG, Pagnano MW, Trousdale RT. Contemporary Revision Total Knee Arthroplasty in Patients Younger Than 50 Years: 1 in 3 Risk of Re-Revision by 10 Years. J Arthroplasty. 2019 Jul;34(7S):S266-S70. Epub 2019/03/03.

What’s New in Musculoskeletal Tumor 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 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Peter S. Rose, MD selected the most clinically compelling findings from the 40 studies summarized in the December 18, 2019 “What’s New in Musculoskeletal Tumor Surgery.

Staging Primary Bone Tumors
–The American Joint Committee on Cancer (AJCC) issued new staging criteria for primary bone tumors,1 largely in response to clinician reports that pelvic and spinal bone tumors have adverse clinical outcomes compared with extremity tumors. In the AJCC staging system, different criteria are applied to extremity, pelvic (inclusive of the sacrum), and mobile spinal tumors—an important step toward gathering data to better define the prognosis of these tumors.

Bone Metastases
–The skeletal system is the third most common site of metastatic disease, and the most common location of symptomatic skeletal metastases is about the hip. In a risk-adjusted analysis of US Veterans Administration data, Philipp et al. showed that patients with femoral metastases treated prophylactically have a lower risk of death (hazard ratio, 0.75) than similar patients treated after pathological fracture.2

Post-Resection Reconstruction
–Aponte-Tinao et al. investigated the ≥10-year survival of bulk allografts for the femur and tibia, demonstrating 60% graft survival in 166 patients.3 However, proximal tibial osteoarticular grafts fared poorly.

Soft-Tissue Sarcomas
–An analysis of the impact of obesity on soft-tissue sarcoma presentation and management4 arrived at 3 conclusions. Relative to non-obese patients,

  1. Obese patients presented with larger tumors (presumably because of difficulty detecting them).
  2. Obese patients required more complex wound closures.
  3. Obese patients experienced more complications.

–A retrospective analysis of the value of radiotherapy and chemotherapy in treating different subtypes of soft-tissue sarcomas5 revealed that myxoid liposarcomas, vascular sarcomas, and myxofibrosarcomas had the greatest benefit from radiation in terms of local control rates, although there was no difference in overall survival. Chemotherapy resulted in a 5% survival benefit.

References

  1. Kniesl JS, Rosenberg AE, Anderson PM, Antonescu C, Bruland O, Cooper K, Horvai A, Holt G, O’Sullivan B, Patel S, Rose P. Bone. In: Amin M.B., Edge S.B., Greene F.L., Byrd D.R., Brookland R.K., Washington M.K., Gershenwald J.E., Compton C.C., Hess K.R., Sullivan D.C., Jessup J.M., Brierley J.D., Gaspar L.E., Schilsky R.L., Balch C.M.,Winchester D.P., Asare E.A., Madera M., Gress D.M., Vega L.M., editors. AJCC cancer staging manual. 8th ed. Springer; 2018. p 471-86.
  2. Philipp T, Mikula J, Doung Y-C, Gundle K. Is there an association between prophylactic femur stabilization and survival in patients with metastatic bone disease? Clin Orthop Relat Res. 2019 May 17. [Epub ahead of print.]
  3. Aponte-Tinao L, Ayerza M, Albergo J, Farfalli GL. Do massive allograft reconstructions for tumors of the femur and tibia survive 10 or more years after implantation? Clin Orthop Relat Res. 2019 May 17. [Epub ahead of print.]
  4. Montgomery C, Harris J, Siegel E, Suva L, Wilson M, Morell S, Nicholas R. Obesity is associated with larger soft-tissue sarcomas, more surgical complications, and more complex wound closures (obesity leads to larger soft-tissue sarcomas). J Surg Oncol. 2018 Jul;118(1):184-91. Epub 2018 Jun 7.
  5. Callegaro D, Miceli R, Bonvalot S, Ferguson P, Strauss DC, Levy A, Griffin A, Hayes AJ, Stacchiotti S, Le P`echoux C, Smith MJ, Fiore M, Dei Tos AP, Smith HG, Catton C, Casali PG, Wunder JS, Gronchi A. Impact of perioperative chemotherapy and radiotherapy in patients with primary extremity soft tissue sarcoma: retrospective analysis across major histological subtypes and major reference centres. Eur J Cancer. 2018 Dec;105:19-27. Epub 2018 Oct 29.

What’s New in Musculoskeletal Basic Science 2019

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 summaries. This month, co-author Philipp B. Leucht, MD selected the most clinically compelling findings from the 40 studies summarized in the December 4, 2019 “What’s New in Musculoskeletal Basic Science.

Muscle Regeneration
–Recent findings about the cellular players in muscle regeneration may allow further development of clinical treatment options for patients with muscle sprains, tears, and loss. Toward that end, Wosczyna et al. established the crucial role of fibroadipogenic progenitors (FAPs, also called mesenchymal stromal cells) in muscle repair and maintenance.1 Using a mouse model, the researchers showed that FAPs are necessary for muscle regeneration by supporting muscle stem cells.

Bone-Brain Crosstalk
–The bone-derived hormone osteocalcin supports development of the musculoskeletal system and the brain. Osteocalcin can regulate anxiety and cognition in adult mice, and Obri et al. postulated that declining levels of osteocalcin may be responsible for the cognitive decline seen in aging.2 This finding may spur investigations into exogenous treatment with osteocalcin to restore brain function.

Tendon Regeneration
–Tendon cells express the transcription factor Scleraxis, which has facilitated the identification of the tendon stem progenitor cell (TSPC). Best and Loiselle identified a Scleraxis-positive cell population in the bridging scar tissue after tendon injury.3 These findings suggest that TSPCs are present in the adult tendon and contribute to the healing response; however, their small number does not result in successful tendon regeneration, but rather in scar formation with interspersed tendon tissue.

–Abraham et al. identified the upregulation of NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) and its downstream targets in tendinopathy-affected human rotator cuff tendons.4 Using a transgenic mouse model in which IKKß (inhibitor of nuclear factor kappa-B kinase subunit beta), a key regulator of inflammation, was overexpressed, they demonstrated the development of tendinopathy in mouse rotator cuff tendons. The deletion of IKKß had a protective effect from chronic overuse.

Bone Regeneration
–Successful bone healing after fracture is highly dependent on the presence and activation of skeletal stem cells. Chan et al. precisely defined the human skeletal stem cell (hSSC), demonstrated the hSSC’s role in human fracture repair, and provided evidence that these cells generate a bone marrow-supportive niche.5 These cells also give rise to bone, cartilage, and stromal progenitor cells.

References

  1. Wosczyna MN, Konishi CT, Perez Carbajal EE, Wang TT, Walsh RA, Gan Q, Wagner MW, Rando TA. Mesenchymal stromal cells are required for regeneration and homeostatic maintenance of skeletal muscle. Cell Rep.2019 May 14;27(7):2029-2035.e5.
  2. Obri A, Khrimian L, Karsenty G, Oury F. Osteocalcin in the brain: from embryonic development to age-related decline in cognition. Nat Rev Endocrinol.2018 Mar;14(3):174-82. Epub 2018 Jan 29.
  3. Best KT, Loiselle AE. Scleraxis lineage cells contribute to organized bridging tissue during tendon healing and identify a subpopulation of resident tendon cells. FASEB J.2019 Jul;33(7):8578-87. Epub 2019 Apr 5.
  4. Abraham AC, Shah SA, Golman M, Song L, Li X, Kurtaliaj I, Akbar M, Millar NL, Abu-Amer Y, Galatz LM, Thomopoulos S. Targeting the NF-κB signaling pathway in chronic tendon disease. Sci Transl Med.2019 Feb 27;11(481):eaav4319.
  5. Chan CKF, Gulati GS, Sinha R, Tompkins JV, Lopez M, Carter AC, Ransom RC, Reinisch A, Wearda T, Murphy M, Brewer RE, Koepke LS, Marecic O, Manjunath A, Seo EY, Leavitt T, Lu WJ, Nguyen A, Conley SD, Salhotra A, Ambrosi TH, Borrelli MR, Siebel T, Chan K, Schallmoser K, Seita J, Sahoo D, Goodnough H, Bishop J, Gardner M, Majeti R, Wan DC, Goodman S, Weissman IL, Chang HY, Longaker MT. Identification of the human skeletal stem cell. 2018; Sep 20;175(1):43-56.e21.

What’s New in Orthopaedic Rehabilitation 2019

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 summaries.

This month, co-author Nitin B. Jain, MD, MSPH selected the most clinically compelling findings from the 40 studies summarized in the November 20, 2019 “What’s New in Orthopaedic Rehabilitation.

Pain Management
–A randomized controlled trial compared pain-related function, pain intensity, and adverse effects among 240 patients with chronic back, hip, or knee pain who were randomized to receive opioids or non-opioid medication.1 After 12 months, there were no between-group differences in pain-related function. Statistically, the pain intensity score was significantly lower in the non-opioid group, although the difference is probably not clinically meaningful. Adverse events were significantly more frequent in the opioid group.

–A series of nested case-control studies found that the use of the NSAID diclofenac was associated with an increase in the risk of myocardial infarction in patients with spondyloarthritis and osteoarthritis, relative to those taking the NSAID naproxen.2

–Intra-articular injections of corticosteroids or hyaluronic acid are often used for pain relief prior to an eventual total knee arthroplasty (TKA). An analysis of insurance data found that patients who had either type of injection within three months of a TKA had a higher risk of periprosthetic joint infection (PJI) after the operation than those who had injections >3 months prior to TKA.

Partial-Thickness Rotator Cuff Tears
–A randomized controlled trial of 78 patients with a partial-thickness rotator cuff compared outcomes of those who underwent immediate arthroscopic repair with outcomes among those who delayed operative repair until completing 6 months of nonoperative treatment, which included activity modification, PT, corticosteroid injections, and NSAIDs.3 At 2 and 12 months post-repair, both groups demonstrated improved function relative to initial evaluations. At the final follow-up, there were no significant between-group differences in range of motion, VAS, Constant score, or ASES score. Ten (29.4%) of the patients in the delayed group dropped out of the study due to symptom improvement.

Stem Cell Therapy
–A systematic review that assessed 46 studies investigating stem cell therapy for articular cartilage repair4 found low mean methodology scores, indicating overall poor-quality research. Only 1 of the 46 studies was classified as excellent, prompting the authors to conclude that evidence to support the use of stem cell therapy for cartilage repair is limited by a lack of high-quality studies and heterogeneity in the cell lines studied.

References

  1. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872-82.
  2. Dubreuil M, Louie-Gao Q, Peloquin CE, Choi HK, Zhang Y, Neogi T. Risk ofcmyocardial infarction with use of selected non-steroidal anti-inflammatory drugs incpatients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Aug;77(8): 1137-42. Epub 2018 Apr 19.
  3. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med. 2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  4. Park YB, Ha CW, Rhim JH, Lee HJ. Stem cell therapy for articular cartilage repair: review of the entity of cell populations used and the result of the clinical application of each entity. Am J Sports Med. 2018 Aug;46(10):2540-52. Epub 2017 Oct 12.

What’s New in Shoulder and Elbow 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 13 subspecialties. Click here for a collection of all such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.

–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4

–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5

Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:

  • Smaller overall lesion size
  • No clear margins of the fragment on MRI
  • Absence of cyst-like lesions

The authors include a nomogram that clinicians can use to predict healing.

UCL Insufficiency
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:

  • Position players returned to play sooner than pitchers, but they had lower rates of return to play.
  • Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).

These findings could help clinicians set expectations for players undergoing UCL reconstruction.

References

  1. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  2. Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
  3. Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
  4. Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
  5. Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
  6. Niu EL, Tepolt FABae DSLebrun DGKocher MSNonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment successJ Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
  7. Camp CL, Conte SD’Angelo JFealy SAFollowing ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequentlyJ Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.

What’s New in Hip Replacement 2019

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 OrthoBuzz Specialty Update summaries. This month, Mengnai Li, MD, co-author of the September 18, 2019 “What’s New in Hip Replacement,” selected the five most clinically compelling findings from among the more than 100 studies summarized in the article.

THA Dislocation
–Pathology involving the spinopelvic relationship has dominated the recent literature on THA dislocation. For patients presenting with a flatback deformity and stiff spine, who had the highest risk of dislocation, the authors of a recent study suggested the use of a dual-mobility implant construct with targeted 30° of anteversion relative to the functional pelvic plane, based on a standing anteroposterior radiograph.1

Preferred Implant Designs
–A study comparing data from the American Joint Replacement Registry with national registry data from other countries found that cementless stem fixation with the use of ceramic and 36-mm heads was the current US preference, while non-US registries indicated that cemented implants and metal and 32-mm heads were used most commonly.2

Opioid Use
–The ongoing effort in the orthopaedic community to reduce opioid consumption without compromising quality of life for joint-replacement patients may be aided by findings from a recent randomized controlled trial. The study found that prescribing 30 immediate-release oxycodone pills instead of 90 pills was associated with a significant reduction in unused pills and decreased opioid consumption without affecting pain scores and patient-reported outcomes.3

Penicillin Allergy
– A retrospective review of >4,900 patients who underwent THA or TKA found that 16.2% reported a history of penicillin allergy. No patients among those with a stated penicillin allergy who were given cefazolin had an adverse reaction. Also, there was no increased rate of surgical site infections among those with a stated penicillin allergy who received clindamycin or vancomycin, although the authors acknowledged that this part of the study was underpowered due to the low overall rate of infection.4

Use of TXA
–Recent guidelines on the use of tranexamic acid (TXA) state that no specific routes of administration, dosage, dosing regimen, or time of administration have been shown to provide clearly superior blood-sparing properties.5

References

  1. Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem. J Arthroplasty.2019 Jan 18. [Epub ahead of print].
  2. Heckmann N, Ihn H, Stefl M, Etkin CD, Springer BD, Berry DJ, Lieberman JR. Early results from the American Joint Replacement Registry: a comparison with other national registries. J Arthroplasty.2019 Jan 5.
  3. 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 Feb 4. [Epub ahead of print].
  4. Stone AH, Kelmer G, MacDonald JH, Clance MR, King PJ. The impact of patient-reported penicillin allergy on risk for surgical site infection in total joint arthroplasty. J Am Acad Orthop Surg.2019 Feb 27. [Epub ahead of print].
  5. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. Tranexamic acid use in total joint arthroplasty: the clinical practice guidelines endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty.2018 Oct;33(10):3065-9. Epub 2018 Aug 7.

What’s New in Limb Lengthening and Deformity Correction 2019

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 OrthoBuzz Specialty Update summaries.

This month, Mark T. Dahl, MD, co-author of the August 21, 2019 What’s New in Limb Lengthening and Deformity Correction,” selected the five most clinically compelling findings from among the 40 noteworthy studies summarized in the article.

Congenital Pseudarthrosis
–Authors of a retrospective study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia found a 69% union rate at maturity. They did not identify specific factors influencing rates of union or refracture, however.1

3-Dimensional Printing
–The models created with this technology can help surgeons preoperatively assess specific anatomical geometries. Corona et al.2 used 3-D-printed titanium truss cages, along with the Masquelet technique, to treat massive infected posttraumatic defects.

Growth Prediction in Limb Lengthening
–A comparative evaluation of the predictive accuracy of 4 methods to correctly time epiphysiodesis in 77 patients found the multiplier method to be the least accurate. In a separate study of 863 epiphysiodeses, authors reported a 7% complication rate.3 The most common complication was incomplete arrest that resulted in angular deformities; half of those cases required reoperation.

Congenital Limb Deficiencies
–Over 16 years, Finnish children born with lower-limb deficiencies had 6 times the number of hospital admissions and 10 times the number of days in hospital per child, compared with children born without a limb deficiency.4

References

  1. Shah H, Joseph B, Nair BVS, Kotian DB, Choi IH, Richards BS, Johnston C, Madhuri V, Dobbs MB, Dahl M. What factors influence union and refracture of congenital pseudarthrosis of the tibia? A multicenter long-term study. J Pediatr Orthop. 2018 Jul;38(6):e332-7.
  2. Corona PS, Vicente M, Tetsworth K, Glatt V. Preliminary results using patient-specific 3D printed models to improve preoperative planning for correction of post-traumatic tibial deformities with circular frames. Injury. 2018 Sep;49(Suppl 2):S51-9.
  3. Makarov MR, Dunn SH, Singer DE, Rathjen KE, Ramo BA, Chukwunyerenwa CK, Birch JG. Complications associated with epiphysiodesis for management of leg length discrepancy. J Pediatr Orthop. 2018 Aug;38(7):370-4.
  4. Syvänen J, Helenius I, Koskimies-Virta E, Ritvanen A, Hurme S, Nietosvaara Y. Hospital admissions and surgical treatment of children with lower-limb deficiency in Finland. Scand J Surg. 2018 Nov 19:1457496918812233. [Epub ahead of print]

What’s New in Musculoskeletal Infection 2019

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 OrthoBuzz Specialty Update summaries.

This month, Thomas K. Fehring, MD, co-author of the July 17, 2019 What’s New in Musculoskeletal Infection,” selected the five most clinically compelling findings—all focused on periprosthetic joint infection (PJI)—from among the more than 90 noteworthy studies summarized in the article.

Preventive Irrigation Solutions
–An in vitro study by Campbell et al.1 found that the chlorine-based Dakin solution forms potentially toxic precipitates when mixed with hydrogen peroxide and chlorhexidine. The authors recommend that surgeons not mix irrigation solutions in wounds during surgery.

PJI Diagnosis
–A clinical evaluation by Stone et al. showed that alpha-defensin levels in combination with synovial C-reactive protein had high sensitivity for PJI diagnosis, but the alpha-defensin biomarker can lead to false-positive results in the presence of metallosis and false-negative results in the presence of low-virulence organisms.

–In an investigation of next-generation molecular sequencing for diagnosis of PJI in synovial fluid and tissue, Tarabichi et al. found that in 28 revision cases considered to be infected, cultures were positive in only 61%, while next-generation sequencing was positive in 89%. However, next-generation sequencing also identified microbes in 25% of aseptic revisions that had negative cultures and in 35% of primary total joint arthroplasties. Identification of pathogens in cases considered to be aseptic is concerning and requires further research.

Treating PJI
–A multicenter study found that irrigation and debridement with component retention to treat PJI after total knee arthroplasty had a failure rate of 57% at 4 years.2

–Findings from an 80-patient study by Ford et al.3 challenge the assumption that 2-stage exchanges are highly successful. Fourteen (17.5%) of the patients in the study never underwent reimplantation, 30% had a serious complication, and of the 66 patients with a successful reimplantation, only 73% remained infection-free. Additionally 11% of the patients required a spacer exchange for persistent infection.

References

  1. Campbell ST, Goodnough LH, Bennett CG, Giori NJ. Antiseptics commonly used in total joint arthroplasty interact and may form toxic products. J Arthroplasty.2018 Mar;33(3):844-6. Epub 2017 Nov 11.
  2. Urish KL, Bullock AG, Kreger AM, Shah NB, Jeong K, Rothenberger SD; Infected Implant Consortium. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: treatment failure is high. J Arthroplasty.2018 Apr;33(4):1154-9. Epub 2017 Nov 21.
  3. Ford AN, Holzmeister AM, Rees HW, Belich PD. Characterization of outcomes of 2-stage exchange arthroplasty in the treatment of prosthetic joint infections. J Arthroplasty.2018 Jul;33(7S):S224-7. Epub 2018 Feb 17.

What’s New in Orthopaedic Trauma 2019

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 OrthoBuzz Specialty Update summaries.

This month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 25 noteworthy studies summarized in the July 3, 2019 What’s New in Orthopaedic Trauma” article.

Proximal Humeral Fractures in the Elderly
–A recent meta-analysis1 analyzing data from >1,700 patients older than 65 who experienced a proximal humeral fracture found no difference in Constant-Murley scores at 1 year between those treated operatively (most with ORIF using a locking plate) and those treated nonoperatively. There was also no between-group difference with respect to reoperation rates among a subgroup of patients from the 7 randomized trials examined in the meta-analysis.

Elbow Dislocation
–A study using MRI to evaluate soft-tissue injuries in 17 cases of “simple elbow dislocation”2 found that the most common soft-tissue injury was a complete tear of the anterior capsule (71% of cases), followed by complete medial collateral ligament (MCL) tears (59%) and lateral collateral ligament tears (53%). These findings challenge previous theories positing that elbow instability starts laterally, with the MCL being the last structure to be injured.

Pertrochanteric Hip Fractures
–A trial randomized 220 patients with a pertrochanteric fracture to receive either a short or long cephalomedullary nail.3 There were no significant differences between the 2 groups at 3 months postsurgery in terms of Harris hip and SF-36 scores, but patients treated with the short nail had significantly shorter operative times, less blood loss, and shorter hospital stays. The incidence of peri-implant fractures between the 2 devices was similar.

 Ankle Syndesmosis Injuries
–A randomized trial involving 97 patients with syndesmosis injuries compared functional and radiographic outcomes between those treated with a single syndesmotic screw and those treated with suture-button fixation. At 6 months, 1 year, and 2 years after surgery, patients in the suture-button group had better AOFAS scores than those in the screw group. CT scans at 2 years revealed a significantly higher tibiofibular distance among the screw group, an increase in malreduction that was noted only after screw removal. That finding could argue against early routine syndesmotic screw removal.

Infection Prevention
–A randomized trial among 470 patients4 facing elective removal of hardware used to treat a below-the-knee fracture compared the effect of intravenous cefazolin versus saline solution in preventing surgical site infections (SSIs). The SSI rate was surprisingly high in both groups (13.2% in the cefazolin group and 14.9% in the saline-solution group), with no statistically significant between-group differences. The authors recommend caution in interpreting these results, noting that there may have been SSI-diagnosis errors and that local factors not applicable to other settings or regions may have contributed to the high SSI rates.

References

  1. Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH,Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg.2018 Aug;27(8):1526-34. Epub 2018 May 4.
  2. Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg.2019 Feb;28(2):341-8. Epub 2018 Nov 8.
  3. Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
  4. Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED,Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI,Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. 2017 Dec 26;318(24):2438-45.

What’s New in Spine 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 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries. This month, Jacob M. Buchowski, MD, MS, coauthor of the June 19, 2019 What’s New in Spine Surgery,” selected the five most clinically compelling findings from among the 47 noteworthy studies summarized in the article.

Predictive Analytics for Deformity Conditions
–A validated model for predicting outcomes after lumbar spine surgery1 found that patients with lower preoperative disability scores, those covered by Medicaid or Workers’ Compensation, and current and previous smokers were less likely to improve with lumbar fusion surgery. Invasiveness of surgery and surgeon and hospital type had lower predictive value.

Early-Onset Scoliosis (EOS)
–A 5-year direct-cost estimate2 comparing magnetic growing rods and conventional growing rods for the treatment of EOS found the total cost for magnetic growing rods to be £34,741 compared with £52,293 for conventional growing rods.

Pediatric Neuromuscular Scoliosis
–A Level-II study investigated patient factors associated with postoperative pulmonary complications among patients with neuromuscular scoliosis who underwent posterior spinal fusion.3 Patients with a history of pneumonia or gastrotomy tube at the time of surgery had an elevated risk of postoperative respiratory infections.

Opioid Consumption
–Findings from a retrospective study of >27,000 patients who underwent lumbar decompression with or without fusion revealed that the majority of patients using prescription opioids discontinued those medications postoperatively. However, among the patients with opioid use >90 days after surgery, the duration of preoperative opioid use was the most important predictor of postoperative opioid use.

Neurological Decline after Adult Spinal Deformity Surgery
–In a retrospective analysis of 265 patients who underwent corrective surgery for adult spinal deformity,4 23% of patients experienced a neurological injury; among those, 33% experienced a major neurological decline. Among the patients with major decline, full recovery was observed in 24% at 6 weeks and 65% at 6 months, but one-third of those patients experienced persistent neurological deficits at 24 months postoperatively. Among patients who experienced a minor neurological injury, 49% reported full recovery at 6 weeks and 70% reported full recovery at 6 months. About one-quarter of those patients showed no improvement at 24 months.

References

  1. Khor S, Lavallee D, Cizik AM, Bellabarba C, Chapman JR, Howe CR, Lu D, Mohit AA, Oskouian RJ, Roh JR, Shonnard N,Dagal A, Flum DR. Development and validation of a prediction model for pain and functional outcomes after lumbar spine surgery. JAMA Surg.2018 Jul 1;153(7):634-42.
  2. Harshavardhana NS, Noordeen MHH, Dormans JP. Cost analysis of magnet-driven growing rods for early-onset scoliosis at 5 years. Spine (Phila Pa 1976).2019 Jan 1;44(1):60-7.
  3. Luhmann SJ, Furdock R. Preoperative variables associated with respiratory complications after pediatric neuromuscular spine deformity surgery. Spine Deform.2019 Jan;7(1):107-11.
  4. Kato S, Fehlings MG, Lewis SJ, Lenke LG, Shaffrey CI, Cheung KMC, Carreon LY, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellisé F, Berven SH. An analysis of the incidence and outcomes of major versus minor neurological decline after complex adult spinal deformity surgery: a subanalysis of Scoli-RISK-1 study. Spine (Phila Pa 1976).2018 Jul 1;43(13):905-12.