For the last 6 years, JBJS has participated in an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of May 2020, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Athletes with Bone-Patellar Tendon-Bone Autograft for ACL Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria than Athletes with Hamstring Tendon Autograft or Soft Tissue Allograft.”
Although the title reveals the findings of this retrospective cohort study, the authors emphasize that “athletes in the allograft and HT groups may be at higher risk of sustaining another knee injury when they return to sport…than those in the BPTB group.” Also, all 79 participants in the study were athletes planning to return to level 1 or 2 sporting activities, so these findings may not be generalizable to all athletes.
In a population-based epidemiological study published in the July 6, 2016 Journal of Bone & Joint Surgery, Tibor et al. found that from 2007 to 2014:
- Many ACL-reconstruction surgeons changed from a transtibial approach to either an anteromedial portal or lateral approach for femoral-tunnel drilling.
- Most did not substantially change the types of grafts they used.
- Many eschewed first-generation bioabsorbable implants in favor of biocomposite fixation devices.
The authors found no change in cumulative revision rates during the study period.
Tibor et al. analyzed information from 21,686 primary ACL reconstructions housed in a Kaiser Permanente registry that collected data from surgeries performed in 33 hospitals by 246 surgeons in urban, rural, and suburban settings in three Western US states. This wide-ranging data set, the authors say, “increases the generalizability of our findings to other community-based surgeons.”
The authors admit, however, that the epidemiological nature of the study “offers only limited insight into associated outcomes,” and they were unable to analyze cost trends because the registry does not capture cost data.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sheldon Lin, MD and Michael Yeranosian, MD, co-authors of the May 18, 2016 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies they cited.
Ankle Fractures and Syndesmotic Injuries
–A randomized study compared syndesmotic fixation versus no fixation in patients with supination-external rotation (SER) IV-type ankle fractures and positive intraoperative stress tests (persistent widening of the medial clear space). At four years of follow-up researchers found no clinical or radiological differences between the two groups.1
–A randomized single-blinded trial to help determine optimal methods for soft-tissue management after ankle trauma compared standard treatment using ice and elevation with the use of multilayer compression bandages. Researchers found that multilayer compression therapy resulted in faster resolution of edema than cryotherapy.
Total Ankle Arthroplasty
–A prospective cohort study found that patients undergoing total ankle arthroplasty (TAA) had higher preoperative expectation scores than did those undergoing ankle arthrodesis. TAA patients were also more likely than arthrodesis patients to report improved postoperative satisfaction scores. Postoperative expectation and satisfaction scores in both groups were closely linked to postoperative Ankle Osteoarthritis Scale (AOS) scores. The study emphasizes the importance of preoperative patient education.2
–A randomized controlled trial looking at union rates in ankle and hindfoot arthrodesis compared the use of recombinant human platelet-derived growth factor BB homodimer (rhPDGF-BB) plus an injectable osteoconductive beta-tricalcium phosphate (β-TCP) collagen matrix to standard autograft. Complete fusion of all involved joints at 24 weeks occurred in 84% of those treated with the growth factor-matrix combination and in 65% of those treated with autograft (p <0.001).3
Patient-Reported Outcomes Assessment
–The 10-center Orthopaedic Foot & Ankle Outcomes Research (OFAR) Network conducted a three-month trial of collecting preoperative and six-month postoperative patient outcome information using the Patient Reported Outcomes Measurement Information System (PROMIS). Of the 328 patients enrolled, 76% completed the preoperative instruments and 43% completed the six-month postoperative instruments. Despite substantial loss to follow-up, the OFAR Network process enabled easy data aggregation and analysis, suggesting its utility in facilitating multicenter trials.4
- Kortekangas THJ, Pakarinen HJ, Savola O, Niinimäki J, Lepojärvi S, Ohtonen P, Flinkkilä T, Ristiniemi J. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2014 Oct;35(10):988-95. Epub 2014 Jun 24.
- Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
- Daniels TR, Younger ASE, Penner MJ, Wing KJ, Le ILD, Russell IS, Lalonde KA, Evangelista PT, Quiton JD, Glazebrook M, DiGiovanni CW. Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int. 2015 Jul;36(7):739-48.Epub 2015 Apr 6.
- Hunt KJ, Alexander I, Baumhauer J, Brodsky J, Chiodo C, Daniels T, Davis WH, Deland J, Ellis S, Hung M, Ishikawa SN, Latt LD, Phisitkul P, SooHoo NF, Yang A, Saltzman CL; OFAR (Orthopaedic Foot and Ankle Outcomes Research Network). The Orthopaedic Foot and Ankle Outcomes Research (OFAR) network: feasibility of a multicenter network for patient outcomes assessment in foot and ankle. Foot Ankle Int. 2014Sep;35(9):847-54.
Attempts by orthopaedists to repair torn human ACLs have failed for the most part, so surgeons now rely almost exclusively on removing the torn ligament and replacing it with autograft or allograft tissue. But now research at Harvard by Martha Murray, MD—a co-author of several JBJS studies—suggests that a torn ACL can be prompted to repair itself.
As Dr. Murray explains in a video, “bridge-enhanced” ACL repair uses stitches and a spongy scaffold injected with the patient’s blood placed between the torn ends of the ACL. The bridge helps healing clots to form and helps surrounding cells grow to rejoin the ends of the ligament. Preclinical studies using this technique have resulted in successful ACL repairs and rates of subsequent knee arthritis that were lower than those seen with reconstruction techniques. Bridge-enhanced ACL repair would also eliminate the need for tissue harvesting in the many patients who choose the autograft reconstruction option.
After reviewing the data from the preclinical studies, the FDA approved the first safety study of this technique in humans, which is now underway.