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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.

What’s New in Shoulder and Elbow 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, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the >40 studies summarized in the October 21, 2020 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A prospective randomized study compared operative and nonoperative treatment of small and medium-sized chronic full-thickness rotator cuff tears. At 10 years, the outcomes of primary repair were superior to those of nonoperative treatment, but both groups improved significantly over time.

Anterior Shoulder Instability
–A randomized trial compared arthroscopic Bankart repair to arthroscopic washout in the treatment of a first-time anterior dislocation. Bankart repair was associated with lower recurrence rates, fewer revisions, and better maintenance of functional outcomes.

–A prospective study evaluated the amount of glenoid bone loss associated with a single instability event in young athletes (average age of 20 years).1 A first-time dislocation was associated with a 6.8% bone loss. In the setting of recurrent instability, total bone loss averaged 10.2% at the time of enrollment and 22.8% after a subsequent instability event.

Proximal Humeral Fractures in the Elderly
–A randomized controlled trial compared locking-plate fixation with reverse total shoulder arthroplasty in treating intra-articular displaced proximal humeral fractures in patients 65 to 85 years of age. At 2 years, Constant-Murley scores were significantly better in the reverse total shoulder arthroplasty group.

“Little League” Elbow
–A prospective MRI-based study of Little League baseball players aged 12 to 15 years2 found that 58% of the players had abnormal upper-extremity MRI findings, and that in 80% of those players, the MRI findings worsened with continued baseball play. The authors suggest that surgeons discourage year-round play in young baseball players.

References

  1. Dickens JF, Slaven SE, Cameron KL, Pickett AM, Posner M, Campbell SE, Owens BD. Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events. Am J Sports Med.2019 Apr;47(5):1082-9.
  2. Holt JB, Pedowitz JM, Stearns PH, Bastrom TP, Dennis MM, Dwek JR, Pennock AT. Progressive elbow magnetic resonance imaging abnormalities in Little League baseball players are common: a 3-year longitudinal evaluation. Am J Sports Med.2020 Feb;48(2):466-72. Epub 2019 Dec 4.

What’s New in Hip Replacement 2020

Every month, JBJS reviews 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, PhD, co-author of the September 16, 2020 What’s New in Hip Replacement,” selected the five most clinically compelling findings from among the 95 noteworthy studies summarized in the article.

Medical Comorbidities and Outcomes of Joint Arthroplasty
–Among 543 malnourished joint arthroplasty patients (with albumin levels <3.4 g/L), an intervention encouraging  a high-protein, anti-inflammatory diet shortened the length of hospital stay and lowered readmissions, relative to malnourished arthroplasty patients who did not receive the intervention.1

Surgical Factors and Outcomes of Total Hip Arthroplasty (THA)
–A multicenter, prospective study used propensity-score matching to compare THA performed with a direct anterior approach with THA performed with a posterolateral approach. Researchers found no patient-reported outcome differences at 1.5 months postoperatively or at ≥1 year up to 5 years.2

Periprosthetic Joint Infection (PJI)
A Musculoskeletal Infection Society workgroup published a recommendation for a 4-tier tool for reporting outcomes after surgical treatment of PJI. Proposed outcomes include infection control with no antibiotic treatment, infection control with suppressive antibiotic therapy, need for reoperation and/or revision and/or spacer retention, and death.

–A meta-analysis found only low-quality retrospective evidence supporting the practice of routinely applying intrawound vancomycin to reduce the rates of PJI. Authors called for a prospective randomized trial before adoption of this practice.3

Postoperative Urinary Retention
–A randomized controlled trial found that preoperative and perioperative administration of tamsulosin did not reduce the incidence of postoperative urinary retention after hip and knee arthroplasty. However, the study included a general male population rather than a higher-risk group.4

References

  1. Schroer WC, LeMarr AR, Mills K, Childress AL, Morton DJ, Reedy ME. 2019 Chitranjan S. Ranawat Award: elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor. Bone Joint J.2019 Jul;101-B(7_Supple_C):17-21.
  2. Sauder N, Vestergaard V, Siddiqui S, Galea VP, Bragdon CR, Malchau H, Elsharkawy KA, Huddleston JI 3rd, Emerson RH. The AAHKS Clinical Research Award: no evidence for superior patient-reported outcome scores after total hip arthroplasty with the direct anterior approach at 1.5 months postoperatively, and through a 5-year follow-up. J Arthroplasty.2020 Feb 12.
  3. Heckmann ND, Mayfield CK, Culvern CN, Oakes DA, Lieberman JR, Della Valle CJ. Systematic review and meta-analysis of intrawound vancomycin in total hip and total knee arthroplasty: a call for a prospective randomized trial. J Arthroplasty.2019 Aug;34(8):1815-22. Epub 2019 Apr 1.
  4. Schubert MF, Thomas JR, Gagnier JJ, McCarthy CM, Lee JJ, Urquhart AG, Pour AE. The AAHKS Clinical Research Award: prophylactic tamsulosin does not reduce the risk of urinary retention following lower extremity arthroplasty: a double-blinded randomized controlled trial. J Arthroplasty.2019 Jul;34(7S):S17-23. Epub 2019 Mar 20.

What’s New in Limb Lengthening and Deformity Correction 2020

Every month, JBJS delivers 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, Andrew G. Georgiadis, MD, co-author of the August 19, 2020 What’s New in Limb Lengthening and Deformity Correction,” selected the five most clinically compelling findings from among the more than 50 noteworthy studies summarized in the article.

Congenital Limb Deficiencies
A study of 42 children with severe fibular hemimelia found that levels of psychosocial adjustment and health-related quality of life were comparable among those who underwent staged reconstruction and those who underwent amputation, at a minimum of 2 years after treatment.

Congenital Dysplasia
–A study evaluating long-term outcomes of 34 patients who were treated with the Charnley-Williams procedure for congenital pseudarthrosis of the tibia found high rates of refracture after initial union, and that failure to operate on the fibula at the time of index surgery resulted in poor outcomes. On a more positive note, 10 of the 13 refractures healed upon retreatment.

Trauma
–A series of 14 patients with aseptic nonunion of the femur or tibia underwent long-bone compression with magnetic lengthening nails programmed “in reverse.”1 The nails shortened by 6.7 mm and the bones shortened by an average of 3.1 mm. Union was achieved in 13 of 14 cases.

Limb Lengthening
–In a study comparing motorized internal lengthening with external fixation for humeral lengthening,2 ultimate lengthening parameters were comparable, but motorized lengthening mitigated pin-site complications and allowed for reuse of the implant.

Pin-Site Management
–A randomized trial of 114 patients with external fixators concluded that there is no role for antiseptic preparations in routine pin care.3 Neither the antiseptic preparation used nor daily dressing changes affected the pin-site infection rate.

References

  1. Fragomen AT, Wellman D, Rozbruch SR. The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report. Arch Orthop Trauma Surg. 2019 Nov;139(11):1551-60. Epub 2019 Jun 19.
  2. Morrison SG, Georgiadis AG, Dahl MT. Lengthening of the humerus using a motorized lengthening nail: a retrospective comparative series. J Pediatr Orthop. 2019 Sep 23. Epub 2019 Sep 23.
  3. Subramanyam KN, Mundargi AV, Potarlanka R, Khanchandani P. No role for antiseptics in routine pin site care in Ilizarov fixators: a randomised prospective single blinded control study. Injury. 2019 Mar;50(3):770-6. Epub 2019 Jan 23.

What’s New in Musculoskeletal Infection 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 OrthoBuzz specialty-update summaries.

This month, Thomas K. Fehring, MD, co-author of the July 15, 2020 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 80 noteworthy studies summarized in the article.

PJI Prevention
–A retrospective case-control study1 found that patients who received an allogeneic blood transfusion during or after knee or hip replacement had a higher risk of PJI than those who were not transfused.

PJI Diagnosis
–A retrospective review2 found that using inflammatory markers to diagnose PJI in immunosuppressed joint-replacement patients is not suitable and that newly described thresholds for synovial cell count and differential have better operative characteristics.

Treating PJI
–A retrospective review3 of a 2-stage debridement protocol with component retention in 83 joint-replacement patients showed an 86.7% success rate of infection control at an average follow-up of 41 months.

–A single-center study4 of perioperative antibiotic selection for patients undergoing total joint arthroplasty found that the risk of PJI was 32% lower among those who received cefazolin compared with those who received other antimicrobial agents. The findings emphasize the importance of preoperative allergy testing in patients with stated beta-lactam allergies.

–A review of regional and state antibiograms5 showed that 75% of methicillin-sensitive S. aureus (MSSA) isolates and 60% of both methicillin-resistant S. aureus (MRSA) and coagulase-negative Staphylococcus isolates were susceptible to clindamycin, whereas 99% of all isolates were susceptible to vancomycin.

References

  1. Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, Puloski S, Smith C, Powell J. Association between allogeneic blood transfusion and wound infection after total hip or knee arthroplasty: a retrospective case-control study. J Bone Jt Infect. 2019 Apr 20;4(2):99-105.
  2. Lazarides AL, Vovos TJ, Reddy GB, Kildow BJ, Wellman SS, Jiranek WA, Seyler TM. Traditional laboratory markers hold low diagnostic utility for immunosuppressed patients with periprosthetic joint infections. J Arthroplasty.2019 Jul;34(7):1441-5. Epub 2019 Mar 12.
  3. Chung AS, Niesen MC, Graber TJ, Schwartz AJ, Beauchamp CP, Clarke HD, Spangehl MJ. Two-stage debridement with prosthesis retention for acute periprosthetic joint infections. J Arthroplasty.2019 Jun;34(6):1207-13. Epub 2019 Feb 16.
  4. Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, Berry DJ, Sierra RJ. 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.
  5. Nodzo SR, Boyle KK, Frisch NB. Nationwide organism susceptibility patterns to common preoperative prophylactic antibiotics: what are we covering? J Arthroplasty.2019 Jul;34(7S):S302-6. Epub 2019 Jan 17.

What’s New in Orthopaedic Trauma 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, co-author Niloofar Dehghan, MD, selected the 5 most clinically compelling findings from the >20 studies summarized in the July 1, 2020 “What’s New in Orthopaedic Trauma.

Hip Fracture
—An international randomized controlled trial (RCT) of hip fracture patients ≥45 years of age1 compared outcomes among 1,487 who underwent an “accelerated” surgical procedure (within 6 hours of diagnosis) and 1,483 who received “standard care” (surgery within 24 hours of diagnosis). Mortality and major complication percentages were similar in both groups, but it is important to note that even the standard-care group had a relatively rapid median time-to-surgery of 24 hours.

—An RCT of nearly 1,500 patients who were ≥50 years of age and followed for 2 years2 compared total hip arthroplasty (THA) with hemiarthroplasty for the treatment of displaced femoral neck fractures. There was no between-group difference in the need for secondary surgical procedures, but hip instability or dislocation occurred in 4.7% of the THA group versus 2.4% of the hemiarthroplasty group. Functional outcomes measured with the WOMAC index were slightly better (statistically, but not clinically) in the THA group. Serious adverse events were high in both groups (41.8% in the THA group and 36.7% in the hemiarthroplasty group). Although the authors conclude that the advantages of THA may not be as compelling as has been purported, THA’s benefits may become more pronounced with follow-up >2 years.

—A preplanned secondary analysis of data from the FAITH RCT examined the effect of posterior tilt on the need for subsequent arthroplasty among older patients with a Garden I or II femoral neck fracture who were treated with either a sliding hip screw or cannulated screws. Patients with a posterior tilt of ≥20° had a significantly higher risk of subsequent arthroplasty (22.4%) compared with those with a posterior tilt of <20° (11.9%). In light of these findings, instead of internal fixation, primary arthroplasty may be an appropriate treatment for older patients who have Garden I and II femoral neck fractures with posterior tilt of >20°.

Ankle Syndesmotic Injury
—An RCT that compared ankle syndesmosis fixation using a suture button with fixation using two 3.5-mm screws3 found a higher rate of malreduction at 3 months postoperatively with screw fixation (39%) than with suture button repair (15%). With the rate of reoperation also higher in the screw group due to implant removal, these findings add to the preponderance of recent evidence that the suture button technique is preferred.

Wound Management
—A 460-patient RCT examining the cost-effectiveness of negative-pressure wound therapy4 for initial wound management in severe open fractures of the lower extremity found the technique to  be associated with higher costs and only marginal improvement in quality-adjusted life-years for patients.

References

  1. HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet.2020 Feb 29;395(10225):698-708. Epub 2020 Feb 9.
  2. Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ; HEALTH Investigators. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med.2019 Dec 5;381(23):2199-208. Epub 2019 Sep 26.
  3. Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy AR; Canadian Orthopaedic Trauma Society. Improved reduction of the tibiofibular syndesmosis with TightRope compared with screw fixation: results of a randomized controlled study. J Orthop Trauma.2019 Nov;33(11):531-7.
  4. Petrou S, Parker B, Masters J, Achten J, Bruce J, Lamb SE, Parsons N, Costa ML; WOLLF Trial Collaborators. Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial. Bone Joint J.2019 Nov;101-B(11):1392-401.

What’s New in Spine 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, co-author Jacob M. Buchowski, MD, selected the 5 most clinically compelling findings from the >30 studies summarized in the June 17, 2020 “What’s New in Spine Surgery.

Adult Spinal Deformity
A recent randomized controlled trial compared operative vs nonoperative treatment among 63 adult patients with symptomatic lumbar scoliosis. An additional 223 patients were included in an observational arm of the study. At 2 years, 64% of the randomized patients in the nonoperative group had crossed over to the operative group. In an as-treated analysis, surgery was associated with superior improvement, but the high crossover rate precludes making firm comparative conclusions.

Spinal Cord Injuries
—A small study of 3 subjects1 who had sustained a spinal cord injury investigated the delivery of spatially selective stimulation to posterior nerve roots innervating the lumbosacral spinal cord through an implantable pulse generator with real-time triggering capability. This method reestablished adaptive control over previously paralyzed muscles, and subjects were eventually able to walk or bike during spatiotemporal stimulation.

Cervical Myelopathy
—A prospective study of >700 patients with degenerative cervical myelopathy2 examined the impact of surgical management on neck pain outcomes. Using the Neck Disability Index at baseline and at 6, 12, and 24 months postoperatively, researchers found significant improvement in functional and pain scores that met or exceeded the minimum clinically important difference at all follow-up time points.

Lumbar Stenosis
—A retrospective study of >1,800 patients with symptomatic lumbar stenosis3 investigated whether pain improvements could be obtained surgically with decompression alone without fusion. At 1 year after surgery, decompression alone was associated with significant improvement in all patient-reported outcomes, suggesting that a concomitant fusion may not be required in such cases.

Opioid Consumption
—A retrospective study of nearly 29,000 patients4 examined the effects of chronic preoperative opioid therapy on medium- and long-term outcomes after lumbar arthrodesis surgery. Postoperatively, chronic opioid use prior to surgery was associated with an increased risk of 90-day emergency department visits and prolonged 1- and 2-year narcotic use.

References

  1. Wagner FB, Mignardot JB, Le Goff-Mignardot CG, Demesmaeker R, Komi S, Capogrosso M, Rowald A, Se´añez I, Caban M, Pirondini E, Vat M, McCracken LA, Heimgartner R, Fodor I, Watrin A, Seguin P, Paoles E, Van Den Keybus K, Eberle G, Schurch B, Pralong E, Becce F, Prior J, Buse N, Buschman R, Neufeld E, Kuster N, Carda S, von Zitzewitz J, Delattre V, Denison T, Lambert H, Minassian K, Bloch J. Courtine G. Targeted neurotechnology restores walking in humans with spinal cord injury. Nature. 2018 Nov;563(7729):65-71. Epub 2018 Oct 31.
  1. Schneider MM, Tetreault L, Badhiwala JH, Zhu MP, Wilson J, Fehlings MG. 42. The impact of surgical decompression on neck pain outcomes in patients with degenerative cervical myelopathy: results from the multicenter prospective AOSpine studies. Spine J. 2019 Sep;19(9):S21.
  2. Bech-Azeddine R, Fruensgaard S, Andersen M, Carreon LY. 215. Outcomes of decompression without fusion in patients with lumbar spinal stenosis with back pain. Spine J. 2019 Sep;19(9):S106.
  3. Eisenberg JM, Kalakoti P, Hendrickson NR, Saifi C, Pugely AJ. 142. Impact of preoperative chronic opioid therapy on long-term outcomes, reoperations, complications and resource utilization after lumbar arthrodesis. Spine J. 2019 Sep; 19(9):S68-9.

What’s New in Foot and Ankle 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, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the 5 most clinically compelling findings from the >60 studies summarized in the May 20, 2020 “What’s New in Foot and Ankle Surgery.

Total Ankle Replacement
—An analysis of a consecutive series of 278 total ankle replacemments1 found that the overall incidence of postoperative complications was 41.7%. However, the clinical outcome was affected in only 7.6% of these cases, as most complications were minor.

Syndesmotic Injuries
—A meta-analysis (total n = 397) found that functional outcomes and complications were similar after suture-button fixation and screw fixation for syndesmotic injuries.2 Time to full weight-bearing, however, was faster among patients receiving suture-button fixation.

Osteochondral Lesions of the Talus
—A prospective cohort study3 examined 101 patients with osteochondral talar lesions of <1.5 cm2. After a minimum follow-up of 36 months, patients treated with microfracture alone (n = 52) and patients treated with microfracture + autologous iliac crest bone marrow aspirate concentrate (BMAC) (n = 49) both reported significant improvement in pain, sport, and activities of daily living. The revision rate was significantly lower in the microfracture + BMAC cohort.

Plantar Fasciitis
—A randomized controlled trial4 compared stretching alone (n = 20) with stretching + proximal medial gastrocnemius recession (n = 20) in patients with >12 months of plantar heel pain. The operative group had significantly greater improvements in functional and pain scores and in forefoot plantar pressure at 12 months of follow-up. Achilles function and calf weakness were similar in both groups.

Clubfoot
A retrospective case series reviewed 220 feet among 145 Nepalese children who had been treated for idiopathic clubfoot with the Ponseti method. At a minimum of 10 years of follow-up, 95% of the 220 feet achieved a plantigrade foot. Surgical treatment, typically a percutaneous Achilles tendon release, was required in 96% of the feet.

References

  1. Clough TM, Alvi F, Majeed H. Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature. Bone Joint J.2018 Oct;100-B(10):1352-8.
  2. Chen B, Chen C, Yang Z, Huang P, Dong H, Zeng Z. To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: a meta-analysis. Foot Ankle Surg.2019 Feb;25(1):63-70. Epub 2017 Aug 18.
  3. Murphy EP, McGoldrick NP, Curtin M, Kearns SR. A prospective evaluation of bone marrow aspirate concentrate and microfracture in the treatment of osteochondral lesions of the talus. Foot Ankle Surg.2019 Aug;25(4):441-8. Epub 2018 Feb 22.
  4. Molund M, Husebye EE, Hellesnes J, Nilsen F, Hvaal K. Proximal medial gastrocnemius recession and stretching versus stretching as treatment of chronic plantar heel pain. Foot Ankle Int.2018 Dec;39(12):1423-31. Epub 2018 Aug 22.

What’s New in Sports Medicine 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, co-author Christopher Y. Kweon, MD selected the 5 most clinically compelling findings from the 40 studies summarized in the April 15, 2020 “What’s New in Sports Medicine.

ACL Graft Choice
—A randomized controlled trial (RCT) comparing bone-tendon-bone autograft, quadrupled hamstring tendon autograft, and double-bundle hamstring autograft for ACL reconstruction in young adults found the following:

  • No between-group differences in patient-reported quality-of-life scores at 5 years
  • Significantly higher rates of traumatic graft reinjuries in the hamstring-tendon and double-bundle groups
  • Relatively low (37%) return to preinjury level of activity for the entire population, with no significant between-group differences

Meniscal Repairs with Bone Marrow Venting
—A double-blinded RCT1 of patients with complete, unstable, vertical meniscal tears compared isolated meniscal repair to meniscal repair with a bone marrow venting procedure (BMVP). Meniscal healing, as assessed with second-look arthroscopy at a mean of 35 weeks, was 100% in the BMVP group and 76% in the control group (p = 0.0035). Secondary pain and function measures at 32 to 51 months were also better in the BMVP group.

Rotator Cuff Repair Rehab
—A multisite RCT2 among >200 patients who received arthroscopic repair of a full-thickness rotator cuff tear compared standard rehabilitation (patients wore a sling at all times except when performing prescribed exercises) and early mobilization (patients wore a sling only when needed for comfort). Early mobilizers showed significantly better forward flexion and abduction at 6 weeks, but no subjective or objective differences (including retear rate) were found at any other time points.

Remplissage for Anterior Shoulder Instability
—A systematic review3 of studies investigating arthroscopic Bankart repair with and without remplissage found significantly higher instability-recurrence rates with isolated Bankart repair. Overall, the addition of remplissage appears to yield better patient-reported function scores compared with isolated Bankart repair alone.

Syndesmotic Ankle Injuries
—A meta-analysis of 7 RCTs (335 patients)4 comparing dynamic versus static fixation for syndesmotic injuries of the ankle found that the overall risk of complications was significantly lower in the dynamic fixation group. Reoperation rates were similar in the two groups, but implant breakage or loosening was reduced with dynamic fixation devices. Compared with static fixation, the dynamic fixation group also had higher AOFAS scores and lower VAS scores at various time points.

References

  1. Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy.2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
  2. Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy.2019 Mar;35(3):749-760.e2.
  3. Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy.2019 Feb;35(2):617-28. Epub 2019 Jan 3.
  4. Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med.2019 Jun 12. [Epub ahead of print].

What’s New in Hand and Wrist 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 Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.

Scaphoid Nonunion
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:

  • Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
  • Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
  • Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.

—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.

Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.

Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4

Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.

References

  1. Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
  2. Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
  3. Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
  4. Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
  5. Rutter M, Grandizio LC, Malone WJ, Klena JC. The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome. J Hand Surg Am.2019 Jan;44(1):35-8. Epub 2018 Nov 27.