Tag Archive | external fixation

Delaying Knee Replacement: Driven to Distraction?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Some symptomatic patients with knee osteoarthritis (OA) present relatively early in the radiographic disease process, while others present after serious articular cartilage loss has occurred. In either case, young knee OA patients are often looking for ways to get relief while postponing a total knee arthroplasty (TKA).

One such recently introduced alternative is knee joint distraction (KJD), a joint-preserving surgery used for bicompartmental tibiofemoral knee osteoarthritis or unilateral OA with limited malalignment. Significant long-term clinical benefit as well as durable cartilage tissue repair have been reported in an open prospective study with 5 years of follow-up.1 A more recent study of distraction2 presents 2-year follow-up results of a 2-pronged trial that measured patient-reported outcomes, joint-space width (JSW), and systemic changes in biomarkers for collagen type-II synthesis and breakdown.

In one arm, end-stage knee OA patients who were candidates for TKA were randomized to KJD (n=20) or TKA (n=40). In the second arm, earlier-stage patients with medial compartment OA and a varus angle <10° were randomized to KJD (n=23) or high tibial osteotomy (HTO; n=46). In the distraction patients, the knee was distracted 5 mm for 6 weeks using external fixators with built-in springs, placed laterally and medially, and weight-bearing was encouraged. WOMAC scores and VAS pain scores were assessed at baseline and at 3, 6, 12, 18, and 24 months.

At 24 months, researchers found no significant differences between the KJD and HTO groups in that part of the trial. In the KJD/TKA arm, there was no difference in WOMAC scores between the two groups, but VAS scores were lower in the TKA group. The improvement in mean joint space width seen at one year in the KJD group of the KJD/TKA arm decreased by two years, though the values were still improved compared to baseline. However, the joint space width improvement seen at 1 year for both groups in the KJD/HTO arm persisted for two years. For all KJD patients, the ratio of biomarkers of synthesis over breakdown of collagen type-II was significantly decreased at 3 months but reversed to an increase between 9 and 24 months.

It is hard to believe that 6 weeks of joint distraction could trigger a process that yields such positive and long-lasting results. While much more research with longer follow-up is needed, KJD may prove particularly useful in younger knee OA patients trying to delay joint replacement.

References

  1. van der Woude, JAD, Wiegant, K, van Roermund, PM, Intema, F, Custers, RJH, Eckstein, F. Five-year follow-up of knee joint distraction: clinical benefit and cartilaginous tissue repair in an open uncontrolled prospective study. Cartilage. 2017;8:263-71.
  2. Jansen MP, Besselink NJ, van Heerwaarden RJ, Roel J.H. Custers1, Jan-Ton A.D. Van der Woude J-TAD, Wiegant K, Spruijt S, Emans PJ, van Roermund PM, Mastbergen SC, Lafeber FP. Knee joint distraction compared with high tibial osteotomy and total knee arthroplasty: two-year clinical, structural, and biomarker outcomes. ORS 2019 Annual Meeting Paper No. 0026 (Cartilage. 2019 Feb 13:1947603519828432. doi: 10.1177/1947603519828432. [Epub ahead of print])

What’s New in Limb Lengthening/Deformity Correction: Level I and II Studies

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. Here is a summary of selected findings from Level I and II studies cited in the August 19, 2015 Specialty Update on limb lengthening and deformity correction:

Pediatric Disorders and Trauma

–A modified guided-growth technique for insertion of tension-band plates decreased operative time, radiation exposure, and incision size.1

–Two meta-analyses concluded that, although oral or intravenous bisphosphonates in children with osteogenesis imperfecta increased bone mineral density, evidence of reduction in fracture rates was inconclusive.2, 3

–A systematic review of 40 studies on surgical management of posttraumatic cubitus varus in children noted an overall complication rate of 14.5%, with no single technique being substantially safer or more effective.4

 Lower-Limb Trauma/Reconstruction in Adults

–A prospective randomized study on the surgical treatment of complex knee dislocations with ligament reconstruction found a significantly lower risk of delayed ligament failure with adjunctive hinged external fixation compared with a hinged knee brace.

–A prospective randomized study comparing biplanar external fixation with reamed interlocking intramedullary nailing for treating open tibial shaft fractures found similar healing rates and functional outcomes one year postoperatively.5

–Patients with extra-articular distal tibial fractures treated with circular external fixators had earlier weight-bearing and superior function compared with those managed with plate fixation.6

–A randomized controlled trial of patients with medial compartment knee osteoarthritis reported similar radiographic outcomes six years postoperatively among those who had opening-wedge high tibial osteotomy compared with those who had undergone closing-wedge high tibial osteotomy. The closing-wedge group had fewer complications but greater prevalence of conversion to total knee arthroplasty.

Foot and Ankle Reconstruction

–A multicenter prospective study comparing ankle arthroplasty with ankle arthrodesis noted similar patient-reported outcomes, although revision rates and major complications were higher following ankle replacement.

Managing Postoperative Complications

–A comparative study noted a lower prevalence of pin-site infections with the use of chlorhexidine (9.2%) compared with povidone-iodine (27.9%) following external fixation.7

–A randomized study revealed a 27% reduction in external fixation time with the use of low-intensity pulsed ultrasound for tibial osteoplasty.8

–A randomized trial in patients undergoing bilateral tibial lengthening showed no improvement in postoperative pain or ankle-joint mobility following botulinum toxin A injection in the calf muscle.9

New Tools and Techniques

–In a matched-pair study, patients undergoing femoral lengthening using a motorized intramedullary nail showed better consolidation indices, better knee mobility, and decreased complication rates compared with conventional external fixation.10

References

  1. MasquijoJJ, Lanfranchi L, Torres-Gomez A, Allende V. Guided growth with the tension band plate construct: a prospective comparison of 2 methods of implant placement. J Pediatr Orthop. 2015 Apr-May;35(3):e20
  2. Dwan K, Phillipi CA, Steiner RD, Basel D. Bisphosphonate therapy for osteogenesis imperfecta. Cochrane Database Syst Rev. 2014;7:CD005088. Epub 2014 Jul 23
  3. Hald JD, Evangelou E, Langdahl BL, Ralston SH. Bisphosphonates for the prevention of fractures in osteogenesis imperfecta: meta-analysis of placebo-controlled trials. J Bone Miner Res.2014 Nov 18
  4. Solfelt DA, Hill BW, Anderson CP, Cole PA. Supracondylar osteotomy for the treatment of cubitus varus in children: a systematic review. Bone Joint J. 2014May;96-B(5):691-700
  5. Rodrigues FL, de Abreu LC, Valenti VE, Valente AL, da Costa Pereira Cestari R,Pohl PH, Rodrigues LM. Bone tissue repair in patients with open diaphyseal tibial fracture treated with biplanar external fixation or reamed locked intramedullary nailing. Injury. 2014 Nov;45(Suppl 5):S32-5
  6. Fadel M, Ahmed MA, Al-Dars AM, Maabed MA, Shawki H. Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia. Int Orthop. 2015 Mar;39(3):513-9. Epub 2014 Dec 5
  7. Cam R, Demir Korkmaz F, Oner Şavk S. Effects of two different solutions used in pin site care on the development of infection. Acta Orthop Traumatol Turc.2014;48(1):80-5
  8. Salem KH, Schmelz A. Low-intensity pulsed ultrasound shortens the treatment time in tibial distraction osteogenesis. Int Orthop. 2014 Jul;38(7):1477-82. Epub 2014 Jan 7
  9. Lee DH, Ryu KJ, Shin DE, Kim HW. Botulinum toxin A does not decrease calf pain or improve ROM during limb lengthening: a randomized trial. Clin Orthop Relat Res.2014 Dec;472(12):3835-41
  10. Horn J, Grimsrud Ø, Dagsgard AH, Huhnstock S, Steen H. Femoral lengthening with a motorized intramedullary nail. Acta Orthop. 2015 Apr;86(2):248-56. Epub 2014 Sep 5