In 2015, JBJS launched 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 April 2017, JBJS and OrthoBuzz readers will have access to the JOSPT article titled “Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial.”
In that randomized clinical trial of 43 patients (50 hips), dry needling was found to be a non-inferior treatment alternative to cortisone injections.
The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.
The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:
- Shoulder OCD in a teenage baseball player that was treated arthroscopically
- Early elbow OCD in young throwers
- Three cases of bilateral femoral head OCD that occurred in multiple members of the same family
Among the take-home points emphasized in this Case Connections article:
- MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
- Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
- There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
Austin Moore’s article “The Self-Locking Metal Hip Prosthesis” was published in The Journal of Bone & Joint Surgery in 1957. Dr. Moore had a lifelong professional interest in hip-fracture surgery and was well aware of the problems associated with reduction and fixation of displaced femoral neck fractures. He had previously designed an internal-fixation device for the management of these injuries and had recognized that perfect reduction, accurate placement of the hip nail, and 100% compliance with non-weight bearing were prerequisites for a satisfactory outcome. For patients in whom those criteria could not be met or those in whom reduction and fixation had failed, an alternate method of managing these fractures was required.
Fourteen years prior to the publication of this landmark article, Dr. Moore had published a case report in The Journal (July 1943) in which he documented the use of a metal prosthesis to replace the proximal end of the femur for a patient with an aggressive giant cell tumour. Some years later the patient succumbed from other causes and the femur was retrieved at autopsy. The specimens demonstrated satisfactory osseointegration of this implant in the proximal femur and encouraged Dr. Moore to experiment with a number of models of proximal femoral implants. This progression of implant design and usage is carefully outlined in this classic paper, which is amply illustrated with radiographs and autopsy specimens of the evolving prosthesis that eventually became known as the Austin Moore hip prosthesis.
This paper is notable for a number of reasons. First, Dr. Moore was able to demonstrate satisfactory fixation using an intramedullary stemmed implant—a significant departure from the early efforts of the Judet brothers and others, who used a small stem in the residual femoral neck in patients being treated for hip arthritis. Secondly, the author developed a specific surgical approach allowing for the insertion of these slightly curved stems into the femur—an approach that is still used today in a number of surgical hip procedures.
Third, Dr. Moore demonstrated the usefulness of proximal femoral replacement in acute displaced femoral neck fractures, avascular necrosis following femoral neck fracture, and non-unions of the femoral neck. He further expanded the use of this implant in the treatment of hip arthritis and documents a number of such cases in this article.
Throughout the article, Dr. Moore emphasizes the importance of meticulous surgical technique, the use of bone ingrowth fixation, careful sizing of the femoral head to the native acetabulum, and the importance of conscientious post-operative care. Finally, he recognized the importance of routine follow-up of endoprostheses and insisted on a yearly visit to ensure appropriate integration of the prosthesis.
In summary, with this article Dr. Moore started a trend of endoprosthetic treatment for displaced femoral neck fractures that is now the standard of care throughout much of the world. During the development of this technique, he demonstrated the importance of bone ingrowth as a method of stabilizing the prosthesis, the importance of good surgical technique, and the value of long-term follow-up in managing patients with hip prostheses. The fact that the implant he designed and reported on 60 years ago is still in widespread use is a reflection of his vision.
James P. Waddell MD, FRCSC
JBJS Deputy Editor
New subspecialty CME exams are now available from The Journal of Bone & Joint Surgery in the following topic areas:
- Adult Hip Reconstruction
- Adult Knee Reconstruction
- Shoulder and Elbow
- Sports Medicine
Each exam consists of 10 questions based on articles published in JBJS within the past 12 months. Exams can be used for study purposes at no cost. Each exam activity may be submitted for a maximum of 5 AMA PRA Category 1 Credits™.
Many orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).
The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.
There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.
From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”
Osteonecrosis of the femoral head is a dreaded complication for patients with a slipped capital femoral epiphysis (SCFE). This complication is far more common with acutely displaced and unstable slips. Safely reducing the femoral head back on the neck while preserving blood supply can often be accomplished with closed reduction maintained by in situ cannulated screw fixation, although some recent efforts to treat SCFE have focused on open approaches.
In the June 15, 2016 edition of The Journal, Schrader et al. demonstrate the benefits of using a simple intracranial pressure (ICP) monitoring probe (see photo) inserted through the cannulated screw to measure femoral head perfusion. While using this technique intraoperatively on 26 hips with SCFE, the authors encountered six hips in which there was no blood flow to the femoral head after closed reduction and screw stabilization. In these situations, they performed percutaneous capsular decompression.
The fact that all patients—even those with no initial femoral head perfusion—left the operating room with measurable blood flow confirms the long-held principle that lack of perfusion can be treated with capsulotomy. The ICP device uses waveforms to measure blood flow and is an accurate gauge of perfusion. Moreover, the technology is available in most hospitals with trauma centers or neurosurgery services.
Having researched femoral head perfusion myself as a young orthopaedist and having kept abreast of more recent findings in this area, I think the monitoring protocol described by Schrader et al. is the best yet published to limit the devastating complication of hip osteonecrosis. I feel that if ICP monitors are available, this protocol should be adopted by all centers treating patients with acute SCFE.
Marc Swiontkowski, MD
While anatomy is the foundation of all surgical practice, we at The Journal do not often publish an-
atomic manuscripts. We make exceptions when papers have the potential to influence the practice of orthopaedic surgery in a major way. Such an exception is the cadaver study by Rudin et al. in the April 6, 2016 JBJS.
The authors focus on the course of the lateral femoral cutaneous nerve (LFCN) of the thigh. This is a highly relevant anatomic structure because of the increasing interest in the anterior approach for hip arthroplasty, for anterior approaches to the hip for open reduction of femoral-head or proximal-femur fractures, and even for surgically treating femoroacetabular impingement.
The major take-home point is the extensive variability of this nerve in terms of where it exits the pelvis and its three different branching patterns from there (see illustration). These anatomic findings should alert the operating surgeon to make skin incisions as lateral as possible and to take extra caution when creating the interval deep to the fascial plane.
Rudin et al. have performed a service to the orthopaedic community by carefully defining the high degree of variability in the course of this nerve, which often is in harm’s way during common surgical exposures. Although injury to the sensory-only LFCN will not lead to major neurological complications, the authors conclude that patients undergoing anterior hip approaches should be informed of the risks of sensory loss or dysesthesia.
Marc Swiontkowski, MD
It’s a good thing orthopaedists don’t rely solely on X-rays to diagnose hip osteoarthritis (OA), because an analysis of data from two large cohort studies casts doubt about the utility of radiographs in diagnosing hip OA in older patients.
Using pain localized to the groin or anterior hip or provoked by internal rotation as the clinical standard for diagnosing hip OA, the researchers compared participants’ reports of such pain with radiographic evidence. In the first cohort study (n=946), only 15.6% of hips in patients reporting frequent hip pain showed radiographic evidence of osteoarthritis. In the second study (n=4366), only 9.1% of hips in patients with frequent pain showed radiographic evidence of hip OA. Conversely, pain was not present in many hips with radiographic evidence of osteoarthritis.
These findings strongly indicate that many cases of hip arthritis would be missed if clinicians relied solely, or even largely, on radiographs. The findings also suggest that overdiagnosis of osteoarthritis would be likely if doctors relied on radiographs rather than examining patients and obtaining an appropriate history. The authors conclude that “health professionals should continue to evaluate and treat patients with hip pain suggestive of osteoarthritis despite negative radiographic findings.” This study is also a good reminder for physicians to treat patients, not imaging studies.
Heterotopic ossification (HO) is a known complication of hip arthroplasty. A double-blind, randomized, placebo-controlled trial by Beckmann et al. in the December 16, 2015 Journal of Bone & Joint Surgery showed that prophylaxis with naproxen dramatically reduced the prevalence of HO after hip arthroscopy, without serious medication-related side effects. These findings bolster findings from previous retrospective investigations that showed large reductions in HO prevalence among those taking nonsteroidal anti-inflammatory drugs (NSAIDs).
The patients in the study took naproxen (500 mg) or a placebo twice a day for three weeks following arthroscopic surgery for femoroacetabular impingement. After one year, the prevalence of radiographically determined HO in patients randomized to the naproxen group was 4% versus 46% in the patients randomized to the placebo group, an 11-fold difference. While the potential for serious GI and renal side effects with NSAIDs is well-documented, in this study only minor adverse reactions to study medication were reported in 42% of those taking naproxen and in 35% of those taking placebo.
Noting that the clinical consequences of HO following hip arthroscopy are “largely undetermined,” the authors still suggest a role for HO prophylaxis “because it could reduce the risk of developing symptomatic HO or requiring revision surgery for HO excision.”
In an accompanying commentary, Sverre Loken praises the authors for the well-designed study, but he cautions that “clinically relevant HO is uncommon, and this has to be weighed against the risk of serious side effects caused by NSAIDs.” He also emphasizes the observation Beckmann et al. make in the last paragraph of their study: that “the lowest dose and shortest duration of NSAID prophylaxis that still prevent HO remain to be determined.”
Patients who experience persistent hip pain after nonoperative treatments for partial or full-thickness gluteus medius tears have two surgical repair options: open or endoscopic. A two-year follow up study by Chandrasekaran et al. in the August 19, 2015 edition of The Journal of Bone & Joint Surgery found that endoscopic repair with correction of identified intra-articular pathology yielded substantial postprocedure functional improvements and pain reduction, along with high levels of overall patient satisfaction. In addition, 15 of the 26 patients who had preoperative gait deviations were found to have a completely normal gait at the two-year follow up. No postoperative complications or re-tears were reported.
The study followed 34 patients (predominantly women, mean age of 57 years) who had endoscopic repairs. Seventeen (50%) of the patients with full-thickness or near full-thickness tears were treated with a suture bridge technique, while the 17 with partial-thickness tears received a transtendinous repair. There was no significant difference in patient-reported outcome measures between the two surgical techniques.
The ability to address intra-articular pathology is touted as an advantage of the endoscopic approach, and in this study concomitant procedures included capsule release, labral debridement and repair, and acetabuloplasty.
Although the Chandrasekaran et al. study did not compare outcomes of endoscopic versus open repair, it did track the largest reported number of endoscopy patients for the longest reported duration.