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, Aaron Chamberlain, MD, co-author of the October 18, 2017 Specialty Update on shoulder and elbow surgery, selected the most clinically compelling findings from among the 36 studies summarized in the Specialty Update.
Reverse Shoulder Arthroplasty
With reverse shoulder arthroplasty, surgeons often have difficulty setting expectations for patients due to the lack of long-term outcomes data. Bacle et al. published a study that describes the clinical outcomes in patients with at least 10 years’ follow-up. Medium-term outcomes among an original cohort of 186 patients had been previously described. Eighty-four of those original patients were available for a mean long-term follow-up of 150 months. The mean overall Constant score fell from 63 at medium-term follow-up to 55 at final follow-up. Active anterior elevation also decreased from 138° to 131.° Despite the decrease in Constant score and ROM between mid- and long-term follow-up, these two measures remained significantly better than preoperative values. Analysis showed a 93% implant survival probability at 120 months. This study will help surgeons counsel patients regarding long-term expectations after reverse shoulder arthroplasty – especially as younger patients are increasingly indicated for this procedure.
Rotator Cuff Repair
A central focus of studies evaluating rotator cuff repair has been to better understand the biological environment that influences tendon healing. Greater understanding of the genetic influence in rotator cuff pathology may lead to interventions that could improve the healing environment. Tashjian et al. reported outcomes after arthroscopic rotator cuff repair in 72 patients who were assessed for family history of rotator cuff tears and underwent a genetic analysis looking for variants in the estrogen-related receptor beta (ESRRB) gene.1 Positive family history and tear retraction were associated with a failure of healing, and lateral tendon retears were associated with both family history and the presence of a single nucleotide polymorphism in the ESRRB gene.
In another recent study focused on the biological healing environment after rotator cuff repair, a prospective randomized trial of platelet-rich plasma (PRP) in patients undergoing repair of a medium to large-sized rotator cuff tear2 found that patients who received PRP experienced an increase in vascularity at the repair site up to 3 months postoperatively. The PRP group also demonstrated better Constant-Murley and UCLA scores and lower retear rates than the no-PRP group, but there was no difference in ASES scores. In another recent randomized trial, 120 patients were randomized to either PRP or ropivacaine injection after rotator cuff repair.3 No between-group differences in clinical outcome scores or retear rates were identified. The contrasting results of these two recent randomized studies illustrate the challenge of identifying any conclusive benefit of PRP in the setting of rotator cuff repair.
Prosthetic Shoulder Infection
Accurate diagnosis of prosthetic shoulder infection continues to present a formidable challenge, given the difficulty of detecting Proprionibacterium acnes (P. acnes) and interpreting when positive results are clinically significant. Development of P. acnes tests that are more rapid and precise in identifying clinically significant infections would be of significant value. Holmes et al. evaluated a PCR restriction fragment length polymorphism (RFLP) technique to identify P. acnes from infected tissue in the shoulder.4 In this study, within 24 hours of sampling, the PCR-RFLP assay detected P. acnes-specific amplicons in as few as 10 bacterial cells.
Approaches to managing clavicle fractures have evolved significantly over the past several decades. While it was once generally accepted that middle third clavicle fractures should be managed nonoperatively, multiple studies have described concerning rates of nonunions and symptomatic malunions. A multicenter prospective trial that randomized patients to either surgical fixation with a plate or nonoperative management identified a nonunion rate of 23.1% in the nonoperatively managed group, compared with a 2.4% nonunion rate in the surgically treated group (p<0.0001). However, the rate of secondary operations was 27.4% in the operatively treated group (most for plate removal) versus 17.1% in the nonoperative group, although that difference did not reach statistical significance (p=0.18). These results will help inform discussions between providers and patients when considering management options for midshaft clavicle fractures.
- Tashjian RZ, Granger EK, Zhang Y, Teerlink CC, Cannon-Albright LA. Identification of a genetic variant associated with rotator cuff repair healing. J Shoulder Elb Surg. 2016. doi:10.1016/j.jse.2016.02.019.
- Pandey V, Bandi A, Madi S, et al. Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial. J Shoulder Elb Surg. 2016;26(3):e82-e83. doi:10.1016/j.jse.2016.01.036.
- Flury M, Rickenbacher D, Schwyzer H-K, et al. Does Pure Platelet-Rich Plasma Affect Postoperative Clinical Outcomes After Arthroscopic Rotator Cuff Repair? Am J Sports Med. 2016. doi:10.1177/0363546516645518.
- Holmes S, Pena Diaz AM, Athwal GS, Faber KJ, O’Gorman DB. Neer Award 2017: A rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder. J Shoulder Elb Surg. 2017. doi:10.1016/j.jse.2016.10.001.
This 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.
How best to treat clavicle fractures remains a controversial question in orthopaedics. A study by Huttunen et al. in the November 2, 2016 JBJS does not resolve that controversy, but it sheds a little light on it.
The authors analyzed a validated Swedish hospital-discharge registry and determined that 44,609 clavicle fractures occurred in that country between 2001 and 2012. During that period, the incidence of clavicle fractures increased by 67%, from 35.6 to 59.3 per 100,000 person-years. During that same time, the rate of surgically treated clavicle fractures increased by 705%, from 2.5% of all clavicle fractures in 2001 to 12.1% in 2012. Surgical treatment was more common in men and in younger age groups. Nevertheless, nearly 90% of clavicle fractures were treated nonsurgically in 2012.
Huttunen et al. remain ambivalent in the discussion section of their study, saying that these and other recent findings “may support surgical treatment of young, active patients who need to return to their previous level of activity in the shortest possible time,” while noting that “high-quality evidence that surgery produces superior long-term results compared with nonoperative treatment remains lacking.”
Since its introduction in the late 20th century, the 2-stage induced membrane technique has been lauded for its bone-reconstruction advantages over alternatives such as distraction osteogenesis and vascularized bone. The cases presented in this month’s “Case Connections” demonstrate that the technique can work with a variety of bone-defect shapes, sizes, and locations.
The springboard case, from the August 10, 2016 edition of JBJS Case Connector, describes 3 cases of chronic post-infection osteomyelitis in children in whom large diaphyseal defects were successfully treated with the induced membrane technique. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 50-year-old diabetic man with a necrotic foot ulcer in whom an extensive midfoot defect was successfully treated with this technique
- successful induced-membrane treatment of a 7-year-old girl with congenital pseudarthrosis of the clavicle
- 2 cases of trauma-caused segmental bone loss that were treated successfully with the induced membrane technique
It is imperative to resolve all active infection before or during stage 1 of this procedure, and careful spacer removal prior to stage 2 is of paramount importance to prevent damage to the induced membrane.
Golf enthusiasts endlessly debate club design and selection when approaching standard situations on the course. For example, for a shot to a large green from 100 yards, one golfer might choose a pitching wedge, while another would opt for a sand wedge or even a chocked-down nine iron. There are no style points in golf for this shot—what matters is getting the ball close to the pin.
There is a strong similarity between this club-selection dilemma and fixation of midshaft clavicle fractures. Two well-done Level I randomized controlled trials in the April 15, 2015 edition of The Journal (van der Meijden et al. and Andrade-Silva et al.) support the notion that, when a patient’s fracture displacement and clinical characteristics warrant fixation, it does not matter whether the surgeon chooses an intramedullary pin or a plate. This decision must be made based on the surgeon’s experience, skill, prior outcomes, and a candid discussion of the options with the patient.
One area of particular concern is the highly comminuted midshaft fracture that is not length-stable. The Andrade-Silva et al. trial showed that, in this setting, the reconstruction plate may well result in clavicular shortening that is statistically greater than shortening with the intramedullary device, but was not found to be clinically important. Still, in those cases a more rigid plate construct may be preferable.
Otherwise, pin or plate achieves equivalent clinical outcomes, just as the sand wedge and pitching wedge can both get the ball close to the pin. It is the experience and skill of the person with the club in hand that matters.
Click here for a commentary by Gordon Groh, MD on the Andrade-Silva et al. article.
Marc Swiontkowski, MD
This is my first Editor’s Choice for OrthoBuzz as new Editor-in-Chief of JBJS. I am following the example of my esteemed predecessor, Vern Tolo, who recently issued an Editor’s Choice warning about our failure to improve the management of patients with fragility fractures in terms of appropriate diagnosis and treatment of underlying osteoporosis. That is a failure of under-treatment. I want to focus on a potential issue of overtreatment.
In the July 2, 2014 JBJS, Leroux et al. describe the risk factors for repeat surgery after ORIF of midshaft clavicle fractures. The study analyzed 1,350 patients treated with surgery between 2002 and 2010 in Ontario. It is important to note that this analysis includes years after 2007, when JBJS published the seminal multicenter RCT on this topic by the Canadian Orthopaedic Trauma Society (COTS). The essence of that study was that ORIF with plate fixation results in a lower rate of nonunion and better functional outcomes predominantly in patients who have completely displaced fractures with about 2 cm of shortening or displacement.
Since that publication, we have seen an explosion in the operative treatment of midshaft clavicle fractures in North America. However, all too often the inclusion criteria derived from the seminal RCT are not referenced in individual patient decision making, and the presence of a clavicle fracture–regardless of degree of displacement–becomes an indication for surgical management.
The findings of the Leroux study should help put a hard stop to this! These researchers found a 24.6% incidence of repeat surgery in this cohort of patients. The most common reoperation was isolated implant removal (18.8%), and the incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothoraces (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Limited surgeon experience increased the risk of reoperation for infection.
The orthopaedic surgery community must heed these data and act upon them. We should not misinterpret the COTS study to “encourage” a patient to opt for surgery if he or she has a midshaft clavicle fracture with less than 2 cm of shortening or displacement. The technical aspects of surgery for midshaft clavicle nonunion is not that different than that for a fresh fracture, so avoidance of nonunion must be thoughtfully discussed with the patient before recommending surgical fixation.
The bottom line that Leroux et al. provide is that surgery for a midshaft clavicle fracture is not a guaranteed success and that surgeon experience matters. And beyond clavicle fractures, let’s be sure we use our literature during shared decision making in an accurate and appropriate manner. That is a basic tenet of professionalism that we all should subscribe to.