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What’s New in Hand and Wrist Surgery 2018

Human Hand Anatomy IllustrationEvery 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, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.

Distal Radius Fractures

—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.1, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.

Scaphoid Fractures

—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.2, which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.

Kienbock Disease

—Lichtman et al.3 introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:

  • How old is the patient?
  • What is the effect of the disease on the lunate?
  • How does the disease affect the wrist?
  • What treatments are available?
  • What are the patient’s requirements?

Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.

Ulnar Impaction

—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.4 noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.

Prescribing Opioids

—Dwyer et al.5 evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.

References

  1. Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
  2. Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
  3. Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
  4. Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
  5. Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.

What’s New in Pediatric Orthopaedics 2018

Pediatrics Image from HUBEvery 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 21, 2018 Specialty Update on Pediatric Orthopaedics, selected the most clinically compelling findings from among the more than 50 studies summarized in the Specialty Update.

Trauma

—An analysis of pediatric femoral shaft fractures before and after the publication of clinical practice guidelines1 revealed a significant increase in the use of interlocked intramedullary nails in patients younger than 11 years of age, and an increase in surgical management for patients younger than 5 years of age. Considerable variability among level-I pediatric trauma centers highlights the need for further outcome studies to facilitate updating of existing guidelines.

Scoliosis

—A prospective cohort study of pain and opioid use among patients following posterior spinal fusion for adolescent idiopathic scoliosis found that increased age, male sex, greater BMI, and preoperative pain levels were associated with increased opioid use. Findings like these may help guide clinicians in opioid dispensing practices that minimize the problem of leftover medication.

Infection

—Two stratification/scoring systems may aid in the early prediction of musculoskeletal infection severity and promote efficient allocation of hospital resources. A 3-tiered stratification system described by Mignemi et al.2 correlated with markers of inflammatory  response and hospital outcomes. Athey et al.3 validated a severity-of-illness score and then modified it for patients with acute hematogenous osteomyelitis.

Hip

—A study of closed reduction for developmental dysplasia of the hip4 revealed that 91% of 87 hips achieved stable closed reduction. Of those, 91% remained stable at the 1-year follow-up. Osteonecrosis occurred in 25% of cases, but it was not associated with the presence of an ossific nucleus, a history of femoral-head reducibility, or age at closed reduction.

—Regardless of obesity status, serum leptin levels increase the odds of slipped capital femoral epiphysis (SCFE), according to a recent study. Researchers reached that conclusion after comparing serum leptin levels in 40 patients with SCFE with levels in 30 BMI-matched controls.

References

  1. Roaten JD, Kelly DM, Yellin JL, Flynn JM, Cyr M, Garg S, Broom A, Andras LM,Sawyer JR. Pediatric femoral shaft fractures: a multicenter review of the AAOS clinical practice guidelines before and after 2009. J Pediatr Orthop.2017 Apr 10. [Epub ahead of print].
  2. Mignemi ME, Benvenuti MA, An TJ, Martus JE, Mencio GA, Lovejoy SA, Copley LA, Williams DJ, Thomsen IP, Schoenecker JG. A novel classification system based on dissemination of musculoskeletal infection is predictive of hospital outcomes. J Pediatr Orthop.2016 Jun 13. [Epub ahead of print].
  3. Athey AG, Mignemi ME, Gheen WT, Lindsay EA, Jo CH, Copley LA. Validation and modification of a severity of illness score for children with acute hematogenous osteomyelitis. J Pediatr Orthop.2016 Oct 12. [Epub ahead of print].
  4. Sankar WN, Gornitzky AL, Clarke NM, Herrera-Soto JA, Kelley SP, Matheney T, Mulpuri K, Schaeffer EK, Upasani VV, Williams N, Price CT; International Hip Dysplasia InstituteClosed reduction for developmental dysplasia of the hip: early-term results from a prospective, multicenter cohort. J Pediatr Orthop.2016 Nov 11. [Epub ahead of print].

What’s New in Adult Reconstructive Knee Surgery 2018, Part II

Knee_smPreviously this month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery. In this OrthoBuzz post, Gwo-Chin Lee, MD, author of the Specialty Update on Adult Reconstructive Knee Surgery, selects his “top five.”

Nonoperative Knee OA Treatment
—Atukorala et al. found a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% of weight loss to achieve a minimal clinically important improvement in function.1

Meniscal Injuries
—A prospective cohort study showed that patients undergoing arthroscopic procedures for degenerative meniscal tears did not have clinically meaningful differences in outcomes compared with patients with traumatic meniscal tears.2

Postoperative Pain Management
—Authors of a Cochrane Systematic Review ascertained that liposomal bupivacaine at the surgical site appears to reduce postoperative pain compared with placebo. However, because of the low quality and volume of evidence, it is not possible to determine its effect compared with conventional agents.3

Avoiding Post-TKA Complications
—In a randomized trial, the use of a tourniquet resulted in upregulation of peptidase activity within the vastus medialis but did not result in an increase in muscular degradation products. The authors concluded that the relationship between tourniquet-induced ischemia and muscle atrophy is complex and poorly understood.4

—The authors of a registry study found no evidence that fondaparinux, enoxaparin, or warfarin are superior to aspirin in the prevention of PE, DVT, or VTE—or that aspirin is safer than these alternatives. However, enoxaparin is as safe as aspirin with respect to bleeding, and fondaparinux is as safe as aspirin with respect to risk of wound complications.5

References

  1. Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is there a dose-response relationship between weight loss and symptom improvement in persons with knee osteoarthritis? Arthritis Care Res (Hoboken). 2016 Aug;68 (8):1106-14.
  2. Thorlund JB, Englund M, Christensen R, Nissen N, Pihl K, Jørgensen U, Schjerning J, Lohmander LS. Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study. BMJ. 2017 Feb 2;356:j356.
  3. Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, Pandit HG. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb 1;2:CD011419.
  4. Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H. Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016 Oct;24(10):3313-21. Epub 2015 Nov 14.
  5. Cafri G, Paxton EW, Chen Y, Cheetham CT, Gould MK, Sluggett J, Bini SA, Khatod M. Comparative effectiveness and safety of drug prophylaxis for prevention of venous thromboembolism after total knee arthroplasty. J Arthroplasty. 2017 Nov;32(11):3524-28.e1. Epub 2017 May 31.

What’s New in Adult Reconstructive Knee Surgery 2018

Knee_smEvery 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery.

Nonoperative Knee OA Treatment

—Intra-articular corticosteroid injections are commonly administered to mitigate pain and inflammation in knee osteoarthritis (OA). However, a randomized controlled trial of 140 patients found that 2 years of triamcinolone injections, when compared with saline injections, resulted in a significantly greater degree of cartilage loss without significant differences in symptoms.1

Non-Arthroplasty Operative Management

—Knee arthroscopy continues to be largely ineffective for pain relief and functional improvement in knee OA. A randomized controlled trial found no evidence that debridement of unstable chondral flaps found at the time of arthroscopic meniscectomy improves clinical outcomes.

Cartilage restoration procedures continue to show varying degrees of success. Long-term results from a randomized trial demonstrated no significant differences in joint survivorship and function between patients undergoing microfracture versus autologous chondrocyte implantation (ACI) at 15 years of follow-up. Nearly 50% of patients in both groups had radiographic evidence of early knee OA.

Periprosthetic Joint Infection

—Periprosthetic joint infection (PJI) remains a leading cause of failure following total knee arthroplasty (TKA). Successful treatment requires accurate diagnosis, and alpha-defensin was found to be both sensitive and specific in the diagnosis of PJI. However, it was not significantly superior to leukocyte esterase (LE) in cases of obvious infection.

—Reported rates of reinfection after 2-stage reimplantation for treatment of a first PJI can be as high as 19%. A 3-month course of oral antibiotics following 2-stage procedures significantly improved infection-free survival without complications.2

Post-TKA Complications from Opioids

—Amid ongoing concerns about opioid misuse, two studies3 suggested that preoperative opioid use was found to be an independent predictor of increased length of stay, complications, readmissions, and less pain relief following TKA.

References

  1. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M,Ward RJ. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. 2017 May 16;317(19):1967-75.
  2. Frank JM, Kayupov E, Moric M, Segreti J, Hansen E, Hartman C, Okroj K,Belden K, Roslund B, Silibovsky R, Parvizi J, Della Valle CJ; Knee Society Research Group. The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial. Clin Orthop Relat Res.2017 Jan;475(1):56-61.
  3. Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty.2017 Sep;32(9):2658-62. Epub 2017 Apr 12.

What’s New in Musculoskeletal Basic Science 2017

Specialty Update Image for OBuzz

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

This month, Matthew J. Allen, VetMB, PhD, author of the December 6, 2017 Specialty Update on Musculoskeletal Basic Science, summarized the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.

Cartilage Repair

–Deriving induced pluripotent stem cells (iPSCs) from peripheral blood cells1 rather than from dermal fibroblasts obviates the need for in vitro expansion. This method may also serve to boost interest in the use of commercial cell-based therapies with defined potency that are available off-the-shelf and don’t require separate cell-harvesting procedures.

–The FDA recommends that large-animal models be used to corroborate basic-science findings from small-animal models. Recent work has demonstrated the efficacy of insulin-like growth factor (IGF)-1 in supporting mechanically competent repair tissue following chondrocyte implantation in a pig model.2

Infection

–Infection, especially from organisms that have developed antimicrobial resistance and/or that produce biofilms, continues to pose a challenging problem for orthopaedic surgeons. To provide a more rational and stratified approach to managing these complex cases, Getzlaf et al. recommend the use of a multidisciplinary approach in which patient-specific information about individual microorganisms is combined with detailed understandings of the vulnerabilities of candidate bacterial species.3

Aseptic Loosening

–There is a resurgence of interest in the role of subclinical infection in the etiopathogenesis of aseptic loosening. At the same time, molecular diagnostic methods for microbial infection are moving forward.4 Such methods may serve to highlight the relevance of subclinical microbial contamination as a cause of aseptic loosening.

Cartilage Imaging

–While the goal of cartilage imaging is to develop tools that are fast, inexpensive, sensitive, accurate, and noninvasive, there is growing interest in the use of more direct, invasive techniques such as optical coherence tomography (OCT),5 which could be used in vivo at the time of surgery to analyze cartilage damage.

References

  1. Li Y, Liu T, Van Halm-Lutterodt N, Chen J, Su Q, Hai Y. Reprogramming of blood cells into induced pluripotent stem cells as a new cell source for cartilage repair. Stem Cell Res Ther.2016 Feb 17;7:31.
  2. Meppelink AM, Zhao X, Griffin DJ, Erali R, Gill TJ, Bonassar LJ, Redmond RW,Randolph MA. Hyaline articular matrix formed by dynamic self-regenerating cartilage and hydrogels. Tissue Eng Part A.2016 Jul;22(13-14):962-70. Epub 2016 Jul 7.
  3. Getzlaf MA, Lewallen EA, Kremers HM, Jones DL, Bonin CA, Dudakovic A,Thaler R, Cohen RC, Lewallen DG, van Wijnen AJ. Multi-disciplinary antimicrobial strategies for improving orthopaedic implants to prevent prosthetic joint infections in hip and knee. J Orthop Res.2016 Feb;34(2):177-86. Epub 2015 Dec 29.
  4. Palmer MP, Melton-Kreft R, Nistico L, Hiller NL, Kim LH, Altman GT, Altman DT, Sotereanos NG, Hu FZ, De Meo PJ, Ehrlich GD. Polymerase chain reaction-electrospray-time-of-flight mass spectrometry versus culture for bacterial detection in septic arthritis and osteoarthritis. Genet Test Mol Biomarkers.2016 Dec;20(12):721-31. Epub 2016 Oct 17.
  5. Novakofski KD, Pownder SL, Koff MF, Williams RM, Potter HG, Fortier LA. High-resolution methods for diagnosing cartilage damage in vivo. 2016 Jan;7(1):39-51.

What’s New in Orthopaedic Rehabilitation 2017

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

This month, Nitin Jain, MD, MSPH, a co-author of the November 15, 2017 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the nearly 50 noteworthy studies summarized in the article.

Pain Management
–Results from a retrospective review1 of patients with noncancer pain highlighted that the risks of long-acting opioids extend beyond overdose, and include increased risks of cardiovascular death and all-cause mortality.

–A randomized prospective trial2 comparing celecoxib, ibuprofen, and naproxen for treating arthritis pain found no significant difference in the hazard ratios for those medications as related to risk of cardiovascular events.

Cost & Quality
–An assessment of a value-improvement initiative3 that examined hip and knee arthroplasty and hip fracture outcomes in a large regional health-care system found reduced costs and improvements in quality of care from 2012 to 2016.

Concussion
–A literature review4 of 7 studies determined that the long-term cognitive and neurogenerative effects of multiple concussions in patients ≤17 years of age remain inconclusive.

Spine
–A randomized trial5 found no difference between anesthetic-only and anesthetic-plus-steroid epidural injections in the treatment of lumbar spinal stenosis.

Shoulder
–A prospective cohort study6 by the MOON Shoulder Group found that the strongest predictor of failure of nonoperative treatment for symptomatic atraumatic rotator cuff tears was lower patient expectations that such treatment would be successful. Pain level, duration of symptoms, and tear anatomy did not predict treatment failure.

References

  1. Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415-23.
  2. Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME,Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V,Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
  3. Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson S,Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH, Anzai Y, Pendleton RC. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
  4. Yumul JN, McKinlay A. Do multiple concussions lead to cumulative cognitive deficits? A literature review. PM&R. 2016 Nov;8(11):1097-103. Epub 2016 May 18.
  5. Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD,Bauer Z, Bresnahan BW, Avins AL, Nedeljkovic SS, Nerenz DR, Standaert C,Kessler L, Akuthota V, Annaswamy T, Chen A, Diehn F, Firtch W, Gerges FJ,Gilligan C, Goldberg H, Kennedy DJ, Mandel S, Tyburski M, Sanders W, Sibell D, Smuck M, Wasan A, Won L, Jarvik JG. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014 Jul 03;371(1):11-21.
  6. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH,Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC,Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.

What’s New in Hip Replacement 2017

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

This month, James T. Ninomiya, MD, MS, lead author of the September 20, 2017 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 50 studies covered in the Specialty Update.

Obesity and THA Outcomes
–Obesity is a well-established risk factor for perioperative THA complications. A prospective registry-based study found that reoperation and implant revision or removal rates increased with increasing BMI. More specifically, increasing BMI was associated with increased rates of early hip dislocation and deep periprosthetic infection.

Infection Prevention
–Two studies 1, 2 demonstrated that patients who have intra-articular injections within 3 months prior to THA experienced nearly double the risk of periprosthetic infection in the first postoperative year, compared with those in noninjection control groups.

Surgical Approaches to THA
–A study of >2,100 patients revealed that, despite claims to the contrary, there were no differences in dislocation rates between those who underwent THA using the direct anterior approach and a propensity-score matched cohort who underwent THA using a posterior approach.3

OR Temperature
–What is the optimal temperature for an orthopaedic operating room? Anecdotes are often used to justify keeping operating rooms at uncomfortably high temperatures, which leads to discomfort and fatigue for members of the surgical team. A comprehensive literature review led authors to suggest that preoperative patient warming, intraoperative patient warming with forced-air devices, and keeping OR temperature at ≤19° C is the ideal combination for comfort while still maximizing patient safety and outcomes.

Return to Driving
–Following joint replacement, patients often ask when it will be safe to return to driving. A meta-analysis of 19 studies concluded that the mean time for return to baseline reaction time for braking was 2 weeks following a right-sided hip replacement and 4 weeks following a right-sided knee replacement.4 The authors stressed, however, that return-to-driving recommendations should be individualized for each patient.

References

  1. Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):166–169.e1. Epub 2016 Apr 22.
  2. Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016 ;31(4):820–3. Epub 2015 Sep 1.
  3. Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):127–30. Epub 2016 Mar 15.
  4. van der Velden CA, Tolk JJ, Janssen RPA, Reijman M. When is it safe to resume driving after total hip and total knee arthroplasty? A meta-analysis of literature on post-operative brake reaction times. Bone Joint J. 2017 ;99-B(5):566–76.

What’s New in Musculoskeletal Infection

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

This month, Arvind Nana, MD, co-author of the July 19, 2017 Specialty Update on musculoskeletal infection, selected the five most compelling findings from among the more than 120 studies cited in the Specialty Update.

Periprosthetic Joint Infection

–Much of the discussion around treating periprosthetic joint infections (PJIs) centers around comparing one-stage versus two-stage exchange arthroplasty. Two-stage exchange arthroplasty requires the use of a temporary cement spacer, and one study1 found that debris from articulating spacers may induce CD3, CD20, CD11(c), and IL-17 changes, raising the possibility of associated immune modulation.

–When performing debridement to treat a PJI, instead of an irrigation solution containing antibiotics, a 20-minute antiseptic soak with 0.19% vol/vol acetic acid reduced the risk of reinfection.2

Spine

–Four studies helped bolster evidence that surgical-site infections are the leading cause of reoperations after spine surgery, both early (within 30 days)3, 4 and late (after 2 years).5, 6

Trauma

–A 100-patient prospective cohort study found that posttraumatic osteomyelitis treated with a 1-stage protocol and host optimization in Type B hosts resulted in 96% infection-free outcomes.7

Shoulder

–As in lower-extremity procedures, the risk of infection after shoulder arthroplasty and arthroscopy is higher when the surgeries are performed less than 3 months after a corticosteroid injection. This finding suggests elective shoulder procedures should be delayed for at least 90 days after such injections.8

References

  1. Singh G, Deutloff N, Maertens N, Meyer H, Awiszus F, Feuerstein B, Roessner A, Lohmann CH. Articulating polymethylmethacrylate (PMMA) spacers may have an immunomodulating effect on synovial tissue. Bone Joint J. 2016 ;98-B(8):1062–8.
  2. Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic acid as part of a debridement protocol during revision total knee arthroplasty. J Arthroplasty. 2017 ;32(3):953–7. Epub 2016 Sep 28.
  3. Medvedev G, Wang C, Cyriac M, Amdur R, O’Brien J. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016 ;41(19):1477–83.
  4. Hijas-Gómez AI, Egea-Gámez RM, Martínez-Martín J, González-Díaz RC, Losada-Viñas JI, Rodríguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain. Spine. November 2016.
  5. Ohya J, Chikuda H, Takeshi O, Kato S, Matsui H, Horiguchi H, Tanaka S, Yasunaga H. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese diagnosis procedure combination database. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 22.
  6. Ahmed SI, Bastrom TP, Yaszay B, Newton PO; Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 9.
  7. McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 ;98-B(9):1289–96.
  8. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 ;25(3):390–7. Epub 2015 Nov 30.

What’s New in Orthopaedic Trauma

Trauma Image for OBuzz.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, David Teague, MD, co-author of the July 5, 2017 Specialty Update on orthopaedic trauma, selected the five most clinically compelling findings from among the 34 studies summarized in the Specialty Update.

Tibial Fractures
A randomized, sham-controlled clinical trial1 failed to demonstrate improved functional recovery or accelerated radiographic healing with the addition of low-intensity pulsed ultrasound (LIPUS) to the postoperative regimen of fresh tibial fractures.

Postsurgical Weight-Bearing
Two studies support early weight-bearing (WB) after certain operatively managed lower extremity injuries, an allowance that may substantially improve a patient’s early independence. One randomized study2demonstrated that immediate WB after locked intramedullary fixation of tibial fractures is not inferior in union time, complication rates, or early function score when compared with a 6-week period of non-WB. The second randomized trial3 found early WB after select ankle fracture fixation (no syndesmosis or posterior malleolar fixation included) resulted in no increase in complications, fewer elective implant removals, and improved 6-week function, relative to late weight-bearing.

Pelvic Injuries
The addition of posterior fixation to anterior fixation for patients with anteroposterior compression type-2 injuries (symphysis disruption, unilateral anterior sacroiliac joint widening) improved radiographic results and led to fewer anterior plate failures.

Hip Fractures
Less femoral neck shortening occurred with cephalomedullary nail fixation devices (2 mm) than with a side plate and lag screw construct (1 cm) when treating OTA/AO 31-A2 intertrochanteric fractures (unstable, 3 or more parts) in patients ≥55 years of age, although functional outcomes were similar for the two groups.

References

  1. Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH; TRUST Investigators writing group. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016 ;355:i5351.
  2. Gross SC, Galos DK, Taormina DP, Crespo A, Egol KA, Tejwani NC. Can tibial shaft fractures bear weight after intramedullary nailing? A randomized controlled trial. J Orthop Trauma. 2016 ;30(7):370–5.
  3. Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016 ;30(7):345–52.

What’s New in Spine Surgery

Spine for O'Buzz.jpegEvery 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, co-author of the June 21, 2017 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies cited in the article.

Biomaterials and Biologics

A multicenter randomized prospective trial compared osteogenic protein-1 (OP-1, also known as bone morphogenetic protein [BMP]-7) combined with local autograft to iliac crest autograft combined with local autograft in posterolateral lumbar fusion. Based on computed tomography (CT) scan assessments, the authors found a 54% fusion rate in the OP-1 group and a 74% fusion rate in the iliac crest group. OP-1 appears to be a poor substitute for iliac crest autograft for achieving posterolateral lumbar fusion.

Adult Spinal Deformity (ASD)

We continue to elucidate the risks and morbidity of adult degenerative spinal deformity surgery. The Scoli-Risk-1 study,1 a Level-III multicenter, prospective observational study, reported on 272 patients with ASD treated surgically. Twenty-two percent of the patients were discharged from the hospital with a decline in the lower-extremity motor score, while only 13% demonstrated improvement. However, by 6 months postoperatively, 21% demonstrated improvement, 69% demonstrated maintenance, and 11% continued to demonstrate lower-extremity motor decline.

Spinal Cord Injury

A Level-I, randomized, crossover trial2 examined whether the character of neuropathic pain following spinal cord injury determined the response to 300 mg/day of either pregabalin or oxcarbazepine. Both anticonvulsant medications significantly improved neuropathic pain in these patients. A subgroup analysis demonstrated that oxcarbazepine was more effective in patients without evoked pain and pregabalin was more effective in patients with evoked pain.

Lumbar Degenerative Spondylolisthesis

To address the consequences of fusion along with decompression in degenerative lumbar spondylolisthesis, a Level-I, randomized controlled trial3 specifically compared laminectomy only with laminectomy plus fusion among 66 patients with stable degenerative spondylolisthesis and symptomatic lumbar stenosis. Patients in the fusion group had significantly higher SF-36 scores at 2, 3, and 4 years, but the groups did not differ with respect to ODI scores at 2 years. The authors reported a significantly higher reoperation rate (34% compared with 14%) in the decompression-only group over the 4-year follow-up, but patients who underwent decompression with fusion began to have an increase in the probability of reoperation 36 months after surgery.

Osteoporotic Injuries

We have more evidence of the effectiveness of vertebral cement augmentation for osteoporotic thoracolumbar compression fractures. The authors of a level-I systematic review and meta-analysis examined randomized controlled trials comparing vertebroplasty with conservative treatment or placebo/sham and identified 11 relevant studies involving 1,048 subjects. The meta-analysis found that patients receiving percutaneous vertebroplasty (n = 531) had lower pain ratings at 1 to 2 weeks, 2 to 3 months, and 1 year. The effect size of vertebroplasty was significant and close to the minimal clinically important difference (MCID).

References

  1. Lenke LG, Fehlings MG, Shaffrey CI, Cheung KM, Carreon L, Dekutoski MB, Schwab FJ, Boachie-Adjei O, Kebaish KM, Ames CP, Qiu Y, Matsuyama Y, Dahl BT, Mehdian H, Pellis´e-Urquiza F, Lewis SJ, Berven SH. Neurologic outcomes of complex adult spinal deformity surgery: results of the prospective, multicenter Scoli-RISK- 1 study. Spine (Phila Pa 1976). 2016 Feb;41(3):204-12.
  2. Min K, Oh Y, Lee SH, Ryu JS. Symptom-based treatment of neuropathic pain in spinal cord-injured patients: a randomized crossover clinical trial. Am J Phys Med Rehabil. 2016 ;95(5):330–8
  3. Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JV, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VK, Barker FG 2nd, Benzel EC. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016 Apr 14;374(15):1424-34.