Every month, JBJS publishes 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 OrthoBuzz summaries of these “What’s New” articles. This month, co-author Kelly Vanderhave, MD selected the 5 most clinically compelling findings from the more than 50 studies summarized in the February 19, 2020 “What’s New in Pediatric Orthopaedic Surgery.”
—ACL reconstruction in pediatric patients continues to receive research attention. A recent review of >560 cases showed that soft-tissue grafts used in this population were twice as likely to fail (13%) as patellar tendon grafts (6%) (p <0.001).1
Septic Arthritis of the Hip
—A multicenter study identified the following independent risk factors for a repeat surgical procedure after initial arthrotomy for septic arthritis of the hip: presenting CRP of >10 mg/dL and ESR of >40 mm/hr, and the presence of osteomyelitis and MRSA.2
Adolescent Idiopathic Scoliosis
—A minimum 20-year follow-up of a cohort study evaluating 180 patients after observation, bracing, or surgical management of adolescent idiopathic scoliosis found the following:
- In the observation cohort, 5 of 36 patients underwent a scoliosis surgical procedure as an adult.
- In the bracing cohort, only 1 of 41 patients required an additional spinal surgical procedure.
- In the surgical cohort, 7 of 103 patients required a revision surgical procedure.
At a mean follow-up of 30 years, there were no significant differences in patient-reported outcomes between the 3 cohorts.3
Infection after Spinal Deformity Surgery
—A retrospective study of >600 pediatric patients who underwent spinal deformity surgery identified 2 independent risk factors among 11 cases of deep surgical site infection that occurred >3 months after the procedure:
- Nonidiopathic scoliosis (e.g., neuromuscular, congenital, and syndromic etiologies)
- High volume of crystalloid administered during surgery (mean of 3.3 ±1.2 L in the group with surgical site infections vs 2.4 ±1.0 L in the infected group)
Redosing antibiotics intraoperatively after 3 hours did not significantly influence the risk of infection.4
Hip Dislocations in Infants with CP
—Among 11 patients (15 hips) with spastic cerebral palsy whose preoperative mean acetabular index was 29°, surgical hip reconstruction (a combination of open reduction, adductor tenotomy, femoral osteotomy, and/or pelvic osteotomy) yielded the following results at a mean follow-up of 40 months:
- Mean migration index of 7%
- Mean acetabular index of 22°
- No instances of osteonecrosis
- 90% achievement and maintenance of hip reduction in those who underwent open reduction with or without pelvic or femoral osteotomy.5
- Ho B, Edmonds EW, Chambers HG, Bastrom TP, Pennock AT. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop. 2018 Aug;38(7):388-92.
- Murphy RF, Plumblee L, Barfield WB, Murphy JS, Fuerstenau N, Spence DD, Kelly DM, Dow MA, Mooney JF 3rd. Septic arthritis of the hip-risk factors associated with secondary surgery. J Am Acad Orthop Surg. 2019 May 1;27(9):321-6.
- Larson AN, Baky F, Ashraf A, Baghdadi YM, Treder V, Polly DW Jr, Yaszemski MJ. Minimum 20-year health-related quality of life and surgical rates after the treatment of adolescent idiopathic scoliosis. Spine Deform. 2019 May;7(3):417-27.
- Du JY, Poe-Kochert C, Thompson GH, Son-Hing JP, Hardesty CK, Mistovich RJ. Risk factors for early infection in pediatric spinal deformity surgery: a multivariate analysis. Spine Deform. 2019 May;7(3):410-6.
- Refakis CA, Baldwin KD, Spiegel DA, Sankar WN. Treatment of the dislocated hip in infants with spasticity. J Pediatr Orthop. 2018 Aug;38(7):345-9.
Every month, JBJS publishes 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, Mengnai Li, MD, co-author of the September 18, 2019 “What’s New in Hip Replacement,” selected the five most clinically compelling findings from among the more than 100 studies summarized in the article.
–Pathology involving the spinopelvic relationship has dominated the recent literature on THA dislocation. For patients presenting with a flatback deformity and stiff spine, who had the highest risk of dislocation, the authors of a recent study suggested the use of a dual-mobility implant construct with targeted 30° of anteversion relative to the functional pelvic plane, based on a standing anteroposterior radiograph.1
Preferred Implant Designs
–A study comparing data from the American Joint Replacement Registry with national registry data from other countries found that cementless stem fixation with the use of ceramic and 36-mm heads was the current US preference, while non-US registries indicated that cemented implants and metal and 32-mm heads were used most commonly.2
–The ongoing effort in the orthopaedic community to reduce opioid consumption without compromising quality of life for joint-replacement patients may be aided by findings from a recent randomized controlled trial. The study found that prescribing 30 immediate-release oxycodone pills instead of 90 pills was associated with a significant reduction in unused pills and decreased opioid consumption without affecting pain scores and patient-reported outcomes.3
– A retrospective review of >4,900 patients who underwent THA or TKA found that 16.2% reported a history of penicillin allergy. No patients among those with a stated penicillin allergy who were given cefazolin had an adverse reaction. Also, there was no increased rate of surgical site infections among those with a stated penicillin allergy who received clindamycin or vancomycin, although the authors acknowledged that this part of the study was underpowered due to the low overall rate of infection.4
Use of TXA
–Recent guidelines on the use of tranexamic acid (TXA) state that no specific routes of administration, dosage, dosing regimen, or time of administration have been shown to provide clearly superior blood-sparing properties.5
- Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem. J Arthroplasty.2019 Jan 18. [Epub ahead of print].
- Heckmann N, Ihn H, Stefl M, Etkin CD, Springer BD, Berry DJ, Lieberman JR. Early results from the American Joint Replacement Registry: a comparison with other national registries. J Arthroplasty.2019 Jan 5.
- Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, Gerlinger TL, Buvanendran A, Della Valle CJ. The James A. Rand Young Investigator’s Award: large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplasty.2019 Feb 4. [Epub ahead of print].
- Stone AH, Kelmer G, MacDonald JH, Clance MR, King PJ. The impact of patient-reported penicillin allergy on risk for surgical site infection in total joint arthroplasty. J Am Acad Orthop Surg.2019 Feb 27. [Epub ahead of print].
- Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. Tranexamic acid use in total joint arthroplasty: the clinical practice guidelines endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty.2018 Oct;33(10):3065-9. Epub 2018 Aug 7.
Early or late dislocation after total hip arthroplasty (THA) is a dreaded complication, and performing a THA to treat a hip fracture is known to increase the risk of postoperative prosthetic joint dislocation. Large-diameter femoral heads, like those used in metal-on-metal implants, offered the prospect of decreased risk of dislocation. Unfortunately, their promise of improved stability was subsequently offset by serious issues with wear. Orthopaedics is notable for technology that promised to solve one problem but led to another, and some wonder whether the increasing popularity of THA using dual-mobility cups to reduce dislocation risk might lead to another example of this paradoxical problem.
However, in the July 17, 2019 issue of The Journal, Jobory et al. published a population-based prospective cohort analysis based on data from the Nordic Arthroplasty Register Association. That study demonstrated a reduced revision risk with dual-mobility acetabular components when THA was performed to treat hip fracture in elderly patients. The authors propensity-score matched 4,520 hip fractures treated with dual-mobility THA to 4,520 hip fractures treated with conventional THA. The study included surgeries from 2001 to 2014, and the median follow-up was 2.4 years for all patients.
Dual-mobility constructs had a lower overall risk of any-component revision (hazard ratio of 0.75), which persisted after authors adjusted for surgical approach (hazard ratio of 0.73). Additionally, the dual-mobility construct had a lower risk of revision due to dislocation (hazard ratio of 0.45), but there was no difference in risk of deep infection between the cohorts. There was no significant difference in risk of any-component revision for aseptic loosening (hazard ratio of 0.544, p=0.052) until the authors adjusted for approach, which resulted in a decreased risk of any-component revision for aseptic loosening (hazard ratio of 0.500, p=0.030). When the authors compared revision of the acetabular component only, they found a reduced risk of revision for any cause as well as revision for dislocation in the dual-mobility cohort using both unadjusted data and data adjusted for surgical approach. Mortality was higher in the dual-mobility group compared with the conventional-component group (hazard ratio of 1.5).
Overall, this study gives us more information regarding the short-term revision risks of an implant design that is gaining popularity in the US. Although dual-mobility constructs seem to be associated with a decreased risk of revision for dislocation in a population of older adults with hip fracture, this data tells us little about this design and technology when used in younger, more active patients, who are at higher risk of polyethylene wear.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered activity on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are the first two:
- Congenital Dislocation of the Hip
PL Ramsey, S Lasser, GD MacEwen: JBJS, 1976 Oct; 58 (7): 1000
The introduction of the Pavlik harness revolutionized the treatment of congenital dislocation of the hip in infants. The concept of the “safe zone” was introduced in this article.
- Two-Stage Reimplantation for the Salvage of Infected Total Knee Arthroplasty
J N Insall, F M Thompson, B D Brause: JBJS, 1983 Jan; 65 (8): 1087
This was the first paper to show that a specific reimplantion protocol (debridement of the soft tissues and removal of the prosthesis and all cement, six weeks of parenteral antibiotics, and implantation of a new total knee) could provide predictable results in managing this difficult problem.