OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.
The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.
The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”
Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.
This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence. This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.
Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.
Moderate evidence: Diabetic patients have a higher risk of complications after TKA.
Moderate evidence: An 8-month delay to TKA does not worsen outcomes.
Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.
Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.
Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.
Strong evidence: The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.
Strong evidence: Drains do not help reduce complications or improve outcomes.
Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.
Strong evidence: All-polyethylene and modular components yield similar outcomes.
Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.
Strong evidence: There is no difference in pain/function with patellar resurfacing.
Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.
Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).
Moderate evidence favors TKA over UKA to avoid future revisions.
Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.
Strong evidence: Rehab/PT started on day of surgery reduces length of stay.
Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.
Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.
The recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.
Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of December 2016:
Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection to the Knee Following Partial Medial Meniscectomy
Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age
Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee
Weight-Bearing Compared with Non-Weight-Bearing Following Osteochondral Autograft Transfer for Small Defects in Weight-Bearing Areas in the Femoral Articular Cartilage of the Knee
Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.
Sport activity continues to increase in priority in modern society. And with a concomitant increase in single-sport focus early in life and near year-round training, the incidence of knee injuries will also continue to increase. Among surgeons and patients, there has been some waning of interest in high tibial osteotomy (HTO) for the most common form of unicompartmental arthritis because results from unicompartmental arthroplasty keep improving, but HTO remains an appropriate choice for patients with very high functional demand.
In the September 21, 2016 issue of The Journal, Ekhtiari et al. report on the findings of a well-conducted systematic review on return-to-work and -sport outcomes of HTO. The authors found that more than four-fifths of patients returned to work or sport, usually within a year after surgery. Approximately four-fifths of patients returned to sport at a level equal to or greater than their preoperative level, and among non-military patients included in the review, 97.8% returned to work at an equal or greater level.
As with most systematic reviews in orthopaedic surgery, the basic concern here is with the quality of the literature that forms the basis of the analysis. The vast majority of studies included in the review were Level IV case series, which leads to concerns about selection and detection bias. Those concerns notwithstanding, a return to sport activity of 87% at a mean follow-up of longer than 5 years is remarkable.
We must recognize that patients who wish to return to sport are the most highly motivated population we serve. HTO should not fall off our radar screen of options for patients with high functional demand and medial compartment arthritis, for they can be some of the most satisfied patients we treat.
Marc Swiontkowski, MD
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 January 20, 2016 Specialty Update on adult reconstructive knee surgery:
Nonsurgical Management and Osteotomy
- A Cochrane database review found that land-based therapeutic exercise programs were modestly beneficial to patients with knee arthritis. Individualized programs were more effective than exercise classes or home-exercise programs.1
- A study comparing intravenous administration of tanezumab versus naproxen and placebo in patients with hip and knee osteoarthritis found that tanezumab effectively relieved pain and improved function at week 16.2
- A comparison of platelet-rich plasma (PRP) injections and hyaluronic acid (HA) injections found both treatments to be equally effective in improving knee function and reducing symptoms as measured by the IKDC subjective score.3
- A study comparing opening-wedge and closing-wedge high tibial osteotomy found that among patients who did not go on to conversion to TKA, there were no between-group differences in clinical or radiographic outcomes at six years of follow-up.
Implants, Instrumentation, and Technique
- A comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting TKA found no differences in pain, function, and radiographic outcomes at a mean of 5.9 years.
- A randomized study of 140 patients that compared the use of patient-specific instrumentation (PSI) and conventional instrumentation found no differences in clinical, operative, and radiographic results.4
- In a randomized trial of 200 patients, the use of electromagnetic computer navigation resulted in insignificantly fewer outliers from the target alignment, compared with the use of conventional instrumentation. There were no between-group differences in clinical outcomes.5
- In a prospective randomized trial, the use of computer-assisted navigation during TKA resulted in lower systemic embolic loads, compared with TKA performed using conventional intramedullary instrumentation.
- A randomized controlled trial comparing kinematically and mechanically aligned TKA found that kinematic alignment with patient-specific guides provided better pain relief and restored better function and range of motion than mechanical alignment using conventional instruments.6
- A randomized study of selective patellar resurfacing in 327 knees followed for a mean of 7.8 years found higher satisfaction among patients with a resurfaced patella.7
Pain and Blood Management
- A randomized controlled trial comparing femoral and adductor canal blocks found that adductor canal blocks decreased time to discharge readiness without an increase in narcotic consumption.8
- A trial comparing periarticular injections (PAIs) of liposomal bupivacaine with conventional bupivacaine PAI found no between-group differences in VAS pain scores 72 hours postoperatively or in patient narcotic consumption.9
- A double-blinded randomized trial comparing topical versus intravenous administration of tranexamic acid found no significant differences in estimated blood loss or complications.
Rehabilitation and Complications
- A randomized trial of 205 post-TKA patients found no differences in WOMAC scores for pain, function, and stiffness in groups that received telerehabilitation or face-to-face home therapy.
- A randomized trial found that Kinesio Taping helped reduce postoperative pain and swelling and improved knee extension during early postoperative rehabilitation.10
- A trial comparing oral edoxaban and subcutaneous enoxaparin for post-TKA thromboprophylaxis found that edoxaban was the more effective agent. The incidence of bleeding events was similar in both groups.11
- Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL.Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev.2015;1:CD004376. Epub 2015 Jan 9.
- Ekman EF, Gimbel JS, Bello AE, Smith MD, Keller DS, Annis KM, Brown MT, WestCR, Verburg KM. Efficacy and safety of intravenous tanezumab for the symptomatic treatment of osteoarthritis: 2 randomized controlled trials versus naproxen. J Rheumatol. 2014 Nov;41(11):2249-59. Epub 2014 Oct 1.
- Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, MarcacciM, Kon E. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015Jul;43(7):1575-82. Epub 2015 May 7.
- Abane L, Anract P, Boisgard S, Descamps S, Courpied JP, Hamadouche M. A comparison of patient-specific and conventional instrumentation for total knee arthroplasty: a multicentre randomised controlled trial. Bone Joint J. 2015 Jan;97-B(1):56-63.
- Blyth MJ, Smith JR, Anthony IC, Strict NE, Rowe PJ, Jones BG. Electromagnetic navigation in total knee arthroplasty-a single center, randomized, single-blind study comparing the results with conventional techniques. J Arthroplasty. 2015Feb;30(2):199-205. Epub 2014 Sep 16.
- Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J. 2014 Jul;96-B(7):907-13.
- Roberts DW, Hayes TD, Tate CT, Lesko JP. Selective patellar resurfacing in total knee arthroplasty: a prospective, randomized, double-blind study. J Arthroplasty.2015 Feb;30(2):216-22. Epub 2014 Sep 28.
- Machi AT, Sztain JF, Kormylo NJ, Madison SJ, Abramson WB, Monahan AM,Khatibi B, Ball ST, Gonzales FB, Sessler DI, Mascha EJ, You J, Nakanote KA, IlfeldBM. Discharge readiness after tricompartment knee arthroplasty: adductor canal versus femoral continuous nerve blocks-a dual-center, randomized trial.Anesthesiology. 2015 Aug;123(2):444-56
- Schroer WC, Diesfeld PG, LeMarr AR, Morton DJ, Reedy ME. Does extended-release liposomal bupivacaine better control pain than bupivacaine after total knee arthroplasty (TKA)? A prospective, randomized clinical trial. J Arthroplasty. 2015Sep;30(9)(Suppl):64-7. Epub 2015 Jun 3.
- Donec V, Kriščiūnas A.The effectiveness of Kinesio Taping after total knee replacement in early postoperative rehabilitation period. A randomized controlled trial. Eur J Phys Rehabil Med. 2014 Aug;50(4):363-71. Epub 2014 May 13.
- Fuji T, Wang CJ, Fujita S, Kawai Y, Nakamura M, Kimura T, Ibusuki K, Ushida H, Abe K, Tachibana S.Safety and efficacy of edoxaban, an oral factor Xa inhibitor, versus enoxaparin for thromboprophylaxis after total knee arthroplasty: the STARS E-3 trial. Thromb Res. 2014 Dec;134(6):1198-204. Epub 2014 Sep 21.
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
- 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
- Dwan K, Phillipi CA, Steiner RD, Basel D. Bisphosphonate therapy for osteogenesis imperfecta. Cochrane Database Syst Rev. 2014;7:CD005088. Epub 2014 Jul 23
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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