JBJS Webinar–Clubfoot: Predicting and Treating Ponseti Method Failures

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The Ponseti method is a proven treatment for idiopathic clubfoot, yielding excellent outcomes with minimal pain or disability. However, as many as 40% of patients fail to respond to initial treatment or develop recurrent deformities.

On Wednesday, January 25, 2017 at 8:00 PM EST, The Journal of Bone & Joint Surgery will host a complimentary webinar that delves into two recent JBJS studies investigating how to predict which patients are most likely to get subpar results from the Ponseti method, and how best to manage clubfoot relapses if they occur.

  • Matthew Dobbs, MD, describes in detail various soft-tissue abnormalities present in patients with treatment-resistant clubfoot that are not present in treatment-responsive patients. These parameters could be used to predict which clubfoot patients are at greater risk of relapse.
  • Jose Morcuende, MD, will spotlight findings from a study that followed treated clubfoot patients for 50 years to determine whether relapses managed with repeat casting and tibialis tendon transfer during early childhood prevented future relapses.

This webinar is moderated by James Kasser, MD, surgeon-in-chief at Boston Children’s hospital and a member of the JBJS Board of Trustees. The webinar will offer additional perspectives on the authors’ presentations from two clubfoot-management experts—Steven Frick, MD and Gregory Mencio, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.

Seats are limited, so register now!

JBJS Reviews Editor’s Choice–Outpatient Joint Replacement?

knee-spotlight-image.png“Necessity is the mother of invention.” In recent years, the demand for total hip, total knee, and unicompartmental knee arthroplasty has grown substantially. However, with limited resources and health-care budgets, there is a need to reduce hospital costs. To that end, a number of surgeons have begun to perform these procedures on an outpatient basis.

Indeed, as the demand for joint replacements grows, it will be imperative to improve patient safety and satisfaction while minimizing costs and optimizing the use of health-care resources. In order to accomplish this goal, surgical teams, nursing staff, and physiotherapists will need to work together to discharge patients from the hospital as soon as safely possible, including on the same day as the operation. The development of accelerated clinical pathways featuring a multidisciplinary approach and involving a range of health-care professionals will result in extensive preoperative patient education, early mobilization, and intensive physical therapy.

In the December 2016 issue of JBJS Reviews, Pollock et al. report on a systematic review that was performed to determine the safety and feasibility of outpatient total hip, total knee, and unicompartmental knee arthroplasty. The authors hypothesized that outpatient arthroplasty would be safe and feasible and that there would be similar complication rates, similar readmission and revision rates, similar clinical outcomes, and decreased costs in comparison with the findings associated with the inpatient procedure. The investigators demonstrated that, in selective patients, outpatient total hip, total knee, and unicompartmental knee arthroplasty can be performed safely and effectively.

A major caveat of this well-conducted study, however, is that, like any systematic review, its overall quality is based on the quality of the individual studies that make up the analysis. In this case, the studies included those that lacked sufficient internal validity, sample size, methodological consistency, and standardization of protocols and outcomes. Thus, going forward, there is a need for more rigorous and adequately powered randomized trials to definitively establish the safety, efficacy, and feasibility of outpatient hip and knee arthroplasty.

Thomas A. Einhorn, MD
Editor, JBJS Reviews

JBJS Editor’s Choice: Advances in Ankle Replacement

Salto Talaris.gifWe have entered an era where total ankle arthroplasty (TAA) is accepted as a rational approach for patients with degenerative arthritis of the ankle. TAA results have been shown to be an improvement over arthrodesis in some recent comparative trials.

That was not always the case, however. In the 1980s, the orthopaedic community attacked ankle joint replacement with gusto, and numerous prosthetic designs were introduced with great enthusiasm based on short-term cohort studies. Unfortunately, the concept of TAA was all but buried as disappointing longer-term results with those older prosthetic designs appeared in the scientific literature. It took a full decade for new designs to appear and be subjected to longer-term follow-up studies before surgeons could gain ready access to more reliable instrumentation and prostheses. The producers of these implants behaved responsibly in this regard, facilitated by an FDA approval process that had increased in rigor.

In the December 21, 2016 issue of The Journal, Hofmann et al. publish their medium-term results with one prosthetic design that was FDA-approved in 2006.  Implant survival among 81 consecutive TAAs was 97.5% at a mean follow-up of 5.2 years. There were only 4 cases of aseptic loosening and no deep infections in the cohort. Total range of motion increased from 35.5° preoperatively to 39.9° postoperatively.

The fact that a high percentage (44%) of ankles underwent a concomitant procedure at the time of TAA attests to the need for careful preoperative planning for alignment of the ankle joint and the need for thorough assessment of the hindfoot. The fact that a substantial percentage (21%) of ankles underwent another procedure after the TAA attests to the need for thoughtful benefit-risk conversations with patients prior to TAA.

I think the TAA concept and procedure are here to stay, but we still have much work to do in fine-tuning prosthetic designs and instrumentation and enhancing surgeon education for more reliable outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Atypical Femoral Fractures: Predicting Post-surgical Healing Problems

Atypical_Femoral_Fracture_2016-12-21.pngOrthopaedic journals and OrthoBuzz have devoted ample space to the apparent association between long-term bisphosphonate use and atypical femoral fractures. The latest insight into this relationship comes from Lim et al. in the December 7, 2016 edition of The Journal of Bone & Joint Surgery. The authors analyzed factors associated with delayed union or nonunion after surgical treatment of 109 atypical femoral fractures in patients who had an average 7.4-year history of bisphosphonate use.

Here’s what Lim et al. found among the 30% of patients studied who had delayed union or nonunion, relative to the 70% who had successful healing:

  • Patient Factors: Patients who had problematic fracture healing had a higher BMI, longer duration of bisphosphonate exposure, and higher rate of prodromal symptoms.
  • Radiographic/Fracture Factors: Supra-isthmic/subtrochanteric fracture location, femoral bowing of ≥10° in the coronal plane, and a lateral/medial cortical thickness ratio of ≥1.4 were predictive of problematic healing.
  • Operative Factors: Iatrogenic cortical breakage around the fracture site and a ratio of ≥0.2 between the remaining gap and the cortical thickness on the anterior and lateral sides of the fracture site were associated with problematic fracture healing.

In an accompanying commentary on the study, Edward J. Harvey, MD notes that most trauma surgeons use cephalomedullary nails to treat atypical femoral fractures, but that “it is impossible from this manuscript to determine what effect the fixation technique had on the outcomes.” He therefore recommends a larger multicenter study using standardized therapy and bone biopsies to further improve understanding in this area.

JBJS Classics: Arthroscopy’s Revolutionary Role in Diagnosing Knee Injuries

JBJS Classics Logo.pngOrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Prior to the advent and subsequently ubiquitous use of MRI that most young surgeons are now accustomed to, it was difficult to determine the incidence of several common sports-related injuriesFrank Noyes’ 1980 classic JBJS manuscript, “Arthroscopy in Acute Traumatic Hemarthrosis of the Knee,” was one of the first articles to establish the clear relationship between hemarthrosis and significant intra-articular knee pathology. While the importance of the anterior cruciate ligament (ACL) had just come to light, Noyes’ landmark findings demonstrated the high incidence of ACL injury in association with acute traumatic hemarthrosis (ATH). Furthermore, he delineated arthroscopy’s critical role in accurately diagnosing other associated knee injuries.

This classic manuscript advocated for the use of arthroscopy as a diagnostic tool for the evaluation of ATH at a time when the consequences of a “knee sprain” with acute swelling were unclear.  In patients who did not have obvious laxity, an existing acute rupture of the ACL was often left undiagnosed during initial clinical evaluations. Noyes’ innovation pushed the field to couple clinical examination with arthroscopy in cases of acute knee injuries, to allow for more accurate diagnosis. Following this paper’s publication, and well into the 1980s, research continued to confirm Noyes’ findings that one of the best uses of arthroscopy was for diagnosis of acute knee injuries.

This paper and another Noyes study[1] were among the first to identify the high rate of serious knee injuries among patients with ATH. Noyes’ JBJS paper showed that 72% of knees with ATH were characterized by some degree of ACL injury. Moreover, in knees with complete ACL disruption, both the anterior drawer and flexion-rotation drawer tests proved to be more accurate diagnostically when performed with the patient under anesthesia than when the tests were performed in the clinic. Further, he also established that ACL tear, meniscus tear, and/or cartilage injury must be included in the differential diagnosis of an ATH.

Noyes’ group revolutionized the course of treatment and care for patients with ATH. While we generally no longer use knee arthroscopy as a diagnostic tool, because of this article, we routinely order MRI in the setting of ATH. Noyes’ piece remains timeless and well-deserving of the title of a “JBJS Classic.”

Robert G. Marx, MD, MSc, FRCSC
JBJS Deputy Editor

Naaman Mehta, BS

Stephen Thompson, MD, MEd, FRCSC
JBJS Deputy Editor

Reference

[1] Noyes FR, Paulos L, Mooar LA, Signer B. Knee Sprains and Acute Knee Hemarthrosis: Misdiagnosis of Anterior Cruciate Ligament Tears. Phys Ther. 60(12): 1596-1601, 1980.

JBJS JOPA Image Quiz: Lateral Clavicle Fracture

clou1.jpgThis month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 64-year-old woman who fell out of bed while sleeping and landed directly on the lateral aspect of the right shoulder. Based on the image shown here and a Zanca view radiograph, she was diagnosed in the emergency room with a lateral clavicle fracture. After staying in a sling for about two weeks, the patient continued to have shoulder pain when using the arm with overhead activities and when sleeping on the shoulder at night.

Select from among four choices as the next best step in treatment: MRI to evaluate the coracoclavicular ligaments, open reduction/internal fixation, continued sling treatment until pain resolves, or transacromial wire fixation.

No Surprise: Infection Biggest Culprit in Amputation for Failed TKA

Cumulative Amputations_12_7_16.gifOf the hundreds of thousands of total knee arthroplasties (TKAs) performed annually around the world, very few result in failure so irreparable that transfemoral amputation is the last resort. But what does “very few” really mean? In the December 7, 2016 issue of The Journal of Bone & Joint Surgery, Gottfriedsen et al. determine the cumulative incidence of amputation for failed TKAs among nearly 93,000 registered knee replacements performed in Denmark from 1997 to 2013.

The authors used a competing-risk model (which took into account the competing risk of death) to avoid overestimating incidence. From a total of 115 amputations performed for causes related to failed TKA, they calculated a cumulative 15-year incidence of amputation of 0.32%. They noted a tendency toward decreasing incidence during the 2008-2013 period, relative to the 1997-2002 period.

The three most common causes of post-TKA amputation were periprosthetic infection (83%), soft-tissue deficiency (23%), and severe bone loss (18%). The authors add, however, that the latter two causes are “most likely the result of long-term infection together with several revision procedures, in which soft tissue and bone stock are gradually damaged.”

The authors encourage orthopaedists to consider newer treatment options to avoid amputation (such as skin grafts and muscle flaps for soft-tissue loss), but they also assert that, in each individual case, those contemporary approaches should be balanced against the “psychological and physical strains related to repeated surgery performed in an attempt to salvage the knee.”

Long-Term, Latarjet Beats Bankart for Anterior Shoulder Instability

Barkart vs Latarjet_12_7_16.gifIn a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.

Specific 10-year outcome comparisons included:

  • Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
  • Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
  • Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
  • Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group

Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”

What’s New in Orthopaedic Rehabilitation

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

This month, Nitin Jain, MD, MSPH, a co-author of the November 16, 2016 Specialty Update on Orthopaedic Rehabilitation, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.

Back Pain

–A prospective cohort study1 evaluating the benefit of early imaging (within 6 weeks of index visit) for patients ≥65 years old with new-onset back pain found that those with early imaging had significantly higher resource utilization and expenditures compared with matched controls who did not undergo early imaging. One year after the index visit, authors found no significant between-group differences in patient-reported pain or disability. They concluded that “early imaging should not be performed routinely for older adults with acute back pain.”

–A randomized clinical trial2 comparing 10 days of NSAID monotherapy with 10 days of NSAIDs + muscle relaxants or opioids for acute nonradicular low back pain found no significant differences across the groups for pain, functional impairment, or use of health care resources. The authors said these findings suggest that combination therapy is not better than monotherapy in this situation, and that the use of opioids in such patients is not indicated.

Rotator Cuff Tears

–A two year follow-up of a randomized trial comparing three treatments for supraspinatus tears (physiotherapy, physiotherapy + acromioplasty, and rotator cuff repair + acromioplasty +physiotherapy) found no significant pain or function differences among the three groups. However, mean tear size was significantly smaller in the cuff-repair group than in the other two.

Pain Medicine

–A meta-analysis3 investigating the use of cannabinoids for managing chronic pain and spasticity concluded that those substances reduced pain and spasticity more than placebo, but the benefits came with an increased risk of side effects such as dizziness, nausea, confusion,  and loss of balance.

Psychosocial Factors

–A randomized controlled trial4 comparing a phone-based cognitive-behavioral/physical therapy (CBPT) program to standard education following lumbar spine surgery found that patients in the CBPT group had greater decreases in pain and disability and increases in general health and physical performance.

References

  1. Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW,Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar17;313(11):1143-53.
  2. Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
  3. Whiting PF, Wolff RF, Deshpande S, DiNisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73.
  4. Skolasky RL, Maggard AM, Li D, Riley LH 3rd., Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil. 2015 Jul;96(7):1200-7. Epub 2015 Mar 28.

JBJS Editor’s Choice—Nonunions of Foot/Ankle Fusions Matter

Ankle_Fusion_12_7_16.pngIn the December 7, 2016 issue of JBJS, Krause et al. analyze data from a 2013 industry-sponsored RCT to investigate correlations between nonunions of hindfoot/ankle fusions indicated by early postoperative computed tomography (CT) and subsequent functional outcomes. Whether nonunion was assessed by independent readings of those CT scans at 24 weeks or by surgeon composite assessments at 52 weeks, patients with failed healing had lower AOFAS, SF-12, and Foot Function Index scores than those who showed osseous union.

This study suggests that a CT should be obtained from patients who are at least 6 months out from a surgical fusion and are not progressing in terms of activity-related pain and function. Depending on the specific CT findings, a repeat attempt at bone grafting, with the possible addition of bone-graft substitute and/or possible modification of internal fixation, may be warranted to forestall later clinical problems.

Krause et al. imply that trusting plain radiographs that show no indication of fusion failure is not acceptable when patient pain and function do not improve in a timely fashion.  Conversely, they conclude that their findings do not support “the concept of an asymptomatic nonunion (i.e., imaging indicating nonunion but the patient doing well),” because nonunions identified early by CT eventually resulted in worse clinical outcomes. The authors also noted that obesity, smoking, and not working increased the risk of nonunion, corroborating findings from earlier studies.

While advanced imaging such as CT is not necessary in foot/ankle fusion patients who are improving in terms of function, pain, and swelling , this study stresses the importance of achieving union following these fusion procedures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief