Tag Archive | JBJS

Smoking Boosts Rate of Reoperation for Infection after TJA

Smoking Image from Nick.jpegHere’s one thing about which medical studies have been nearly unanimous:  Smoking is a health hazard by any measure. In the February 15, 2017 edition of The Journal of Bone & Joint Surgery, Tischler et al. put some hard numbers on the risk of smoking for those undergoing total joint arthroplasty (TJA).

After controlling for confounding factors, the authors of the Level III prognostic study found that:

  • Current smokers have a significantly increased risk of reoperation for infection within 90 days of TJA compared with nonsmokers.
  • The amount one has smoked, regardless of current smoking status, significantly contributed to increased risk of unplanned nonoperative readmission.

In a commentary on the Tischler et al. study, William, G. Hamilton, MD says, “…as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health.”

JBJS Editor’s Choice—VTE Risk with Metastatic Skeletal Lesions: Fix Prophylactically or Not?

swiontkowski-marc-colorIn the February 15, 2017 issue of The Journal, Aneja et al. utilize a large administrative database to examine the critical question of venous thromboembolism (VTE)  risk as it relates to managing patients with metastatic femoral lesions. The authors found that prophylactic intramedullary (IM) nailing clearly resulted in a higher risk of both pulmonary embolism and deep-vein thrombosis, relative to IM nailing after a pathologic fracture.  Conversely, the study found that patients managed with fixation after a pathological fracture had greater need for blood transfusions, higher rates of postoperative urinary tract infections, and a decreased likelihood of being discharged to home.

The VTE findings make complete clinical sense, because when we ream an intact bone, the highly pressurized medullary canal forces coagulation factors into the peripheral circulation. When we ream after a fracture, the pressures are much lower, and neither the coagulation factors nor components of the metastatic lesion are forced into the peripheral circulation as efficiently, although some may partially escape through the fracture site.

One might conclude that we should never consider prophylactic fixation in the case of metastatic disease in long bones, but that would not be a patient-centric position to hold. In my opinion, the decision about whether to prophylactically internally fix an impending pathologic fracture should be based on patient symptoms and consultations with the patient’s oncologist and radiation therapist.

If all of the findings from Aneja et al. are considered, and if the patient’s symptoms are functionally limiting after initiation of appropriate radiation and chemotherapy, prophylactic fixation should be performed, along with vigilantly managed VTE-prevention measures. This study is ideally suited to inform these discussions for optimum patient care.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Adult Reconstructive Knee Surgery

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, Gwo-Chin Lee, MD, author of the January 18, 2017 Specialty Update on Adult Reconstructive Knee Surgery, selected the five most clinically compelling findings from among the more than 100 studies summarized in the Specialty Update.

Nonoperative Knee OA Treatment

—Weight loss is one popular nonoperative recommendation for treating symptoms of knee osteoarthritis (OA). An analysis of data from  the Osteoarthritis Initiative found that delayed progression of cartilage degeneration, as revealed on MRI and clinical symptoms, positively correlated with BMI reductions >10% over 48 months.1

Total Knee Arthroplasty

—In total knee arthroplasty (TKA), the drive toward producing normal anatomy has led to explorations of alternative alignment paradigms. A prospective randomized study found that small deviations from the traditional mechanical axis (known as kinematic alignment) can be well tolerated and do not lead to decreased survivorship or poorer functional outcomes at short-term follow up.2

—Controversy exists about the optimal method to achieve stemmed implant fixation in revision TKA.  A randomized controlled trial of TKA patients with mild to moderate tibial bone loss found no difference in tibial implant micromotion between cemented and hybrid press-fit stem designs, based on radiostereometric analysis.

Blood Management in TKA

—Minimizing blood loss and transfusions is crucial to minimizing complications after TKA. A randomized, double-blind, placebo-controlled trial found that intra-articular and intravenous administration of tranexamic acid (TXA) was more effective than intravenous TXA alone, without an increased risk of venous thromboembolism (VTE).  However, the optimal regimen for TXA remains undefined.

VTE/PE Prophylaxis

—VTE prophylaxis is essential for all patients undergoing TKA. A risk-stratification study of pulmonary embolism (PE) after elective total joint arthroplasty reported that the incidence of PE within 30 days after either hip or knee replacement was 0.5%. Risk factors associated with PE were age of > 70 years, female sex, and higher BMI. The presence of anemia was protective against PE.  The authors developed an easy-to-use scoring system to determine risk for VTE to help guide chemical prophylaxis.3

References

  1. Gersing AS, Solka M, Joseph GB, Schwaiger BJ, Heilmeier U, Feuerriegel G, Nevitt MC, McCulloch CE,Link TM. Progression of cartilage degeneration and clinical symptoms in obese and overweight individuals is dependent on the amount of weight loss: 48-month data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2016 Jul;24(7):1126-34. Epub 2016 Jan 30.
  2. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M. PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 27. [Epub ahead of print]
  3. Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and validation of a risk stratification system for pulmonary embolism after elective primary total joint arthroplasty. J Arthroplasty. 2016 Sep;31(9)(Suppl):187-91. Epub 2016 Mar 17.

 

JBJS Classics: Wiltse’s Paraspinal Muscle-Splitting Approach

JBJS Classics Logo.pngOrthoBuzz 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 by clicking on the “Leave a Comment” button in the box to the left.

Almost 50 years ago, in a classic 1968 JBJS paper, Leon Wiltse and co-authors described a novel and innovative access route to the lumbar spine. At that time, the vast majority of approaches to the lumbar spine were performed through midline incisions. Wiltse´s approach, however, utilized a more lateral access route to the spine. In this beautifully illustrated paper, the authors described a curved incision of the fascia and the skin with direct access to the transverse processes, pedicles, and the lateral masses.

The advantages of this novel access were multifold. Although wide midline laminectomies represented the gold-standard decompression technique at that time, the lateral approach served to avoid a more challenging and risky midline revision access, adding an elegant access for salvage procedures. Two goals of Wiltse’s approach were to achieve solid, posterolateral fusions and to decompress the neural structures. Graft harvest from the posterior iliac crest was easily facilitated with this approach.

Additional advantages included reduced blood loss and less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments, which served to maintain the stability of the lumbar spine. The main downside was the necessity of performing two skin incisions as opposed to just one midline incision.

Since its introduction, Wiltse´s approach and the anatomic planes have been studied in great detail.1,2 Considering the vast developments in spine surgery over the last years and decades, the Wiltse approach has stood the test of time, as it still represents one of the main access routes to the lumbar spine that any skilled spine surgeon needs to master.

With the arrival of instrumentation, Wiltse´s approach was later employed in interbody fusion and minimally invasive transforaminal lumbar interbody fusion (TLIF) techniques, as it allowed direct access to the pedicles and the disc space. It has also been used for various techniques of direct pars repair.3

With the addition of some minor modifications, Wiltse´s approach still reflects the main access for minimally invasive, microsurgical treatment of foraminal and extraforaminal disc herniations, including bony decompression of the neuroforamen.4 The far lateral access permits sufficient decompression of the exiting nerve roots while preserving the facet joints, which serves to avoid more invasive fusion techniques for a considerable number of patients.

Overall, Wiltse´s innovative approach advanced spinal care by reducing access–related morbidity. Dr. Wiltse passed away at age 92 in 2005. His major achievements in spine surgery and his great accomplishments will remain in our memories and will continue to impact spine surgery over the coming decades.

Christoph J. Siepe, MD
JBJS Deputy Editor

References

  1. Vialle R, Court C, Khouri N, et al. Anatomical study of the paraspinal approach to the lumbar spine. Eur Spine J. 2005;14(4):366-71.
  2. Palmer DK, Allen JL, Williams PA, et al. Multilevel magnetic resonance imaging analysis of multifidus-longissimus cleavage planes in the lumbar spine and potential clinical applications to Wiltse’s paraspinal approach. Spine (Phila Pa 1976). 2011;36(16):1263-7.
  3. Xing R, Dou Q, Li X, et al. Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery. Spine (Phila Pa 1976). 2016;41(8):E494-502.
  4. Mehren C, Siepe CJ. Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach. Eur Spine J. 2016.

During Deployment, Military Orthopaedist Discovers What’s Important

WI_Krueger.pngThe February 1, 2017 issue of JBJS contains the fourth of a series of personal essays in which orthopaedic clinicians tell a story about a high-impact lesson they learned that has altered their worldview, enhanced them personally, and positively affected the care they provide as orthopaedic
physicians.

This “What’s Important” piece comes from Dr. Chad Krueger of the Womack Army Medical Center. In his essay titled “Being Present,” Dr. Krueger emphasizes that family and friends are too easily taken for granted amid clinical and research demands.

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

For Perthes Disease, Are Two Osteotomies Better than One?

LCP_Osteotomies.pngIt is well accepted that kids with Legg-Calve-Perthes (LCP) disease do best when their condition is diagnosed and managed before 6 years of age. Surgical treatment is often recommended for children 6 years and older who have more severe femoral-head involvement, and orthopaedists perform combined pelvic and femoral varus osteotomies on some of those children.

In the February 1, 2107 edition of The Journal, Mosow et al. compare 10-year outcomes in 52 LCP patients who underwent combined osteotomies (mean age at surgery of 7.9 years) with results reported in the literature for single pelvic or femoral osteotomies. Although the postoperative radiographic and functional results after combined osteotomy were good, they were overall no better than those reported in the literature for either osteotomy alone.

The authors admit that in the absence of a randomized study design, these findings should be interpreted with caution, but they conclude that “it is not recommended that combined osteotomies for this age group routinely be used.”

JBJS Editor’s Choice: Sarcopenia + Acetabular Fracture = Increased Mortality

Sarcopenia CT.gifIn the February 1, 2017 edition of The Journal, Deren et al. provide an important analysis of muscle mass as it relates to mortality in older patients with an acetabular fracture. Among 99 fracture patients studied retrospectively, 42% had sarcopenia, defined in this study as a skeletal muscle index at the L3 vertebral body of <55.4 cm2/m2  for men and <38.5 cm2/m2  for women.

Deren et al. found that low BMI was associated with sarcopenia and that patients with sarcopenia were significantly more likely than patients without sarcopenia to sustain their skeletal injury from a low-energy mechanism. Sarcopenia was also associated with a higher risk of 1-year mortality, especially when in-hospital deaths were excluded. While the authors note that there’s no consensus definition for clinically diagnosing sarcopenia, they conclude that “sarcopenia based on the skeletal muscle index may be a better predictor of mortality than other commonly used classification
systems.”

There are important subtextual messages in this study for all physicians who manage geriatric patients. Maintenance of muscle mass by resistance exercise (lifting weights, isometrics, etc.) is of critical importance in limiting fall risk and maintaining good balance and bone density. Dietary considerations are intertwined with exercise in maintaining muscle mass among older patients. Resistance training and cardio exercise help to maintain appetite, and adequate protein intake is of utmost importance. When families and medical teams work together, the risk of sarcopenia can be minimized, resulting in lower rates of falls, fewer low-energy fractures, and less mortality.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

New Knee Content from JBJS

knee-spotlight-image.pngThe 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 February 2017:

  • Comparison of Highly Cross-Linked and Conventional Polyethylene in Posterior Cruciate-Substituting Total Knee Arthroplasty in the Same Patients

  • What’s New in Adult Reconstructive Knee Surgery

  • Hinged External Fixation in the Treatment of Knee Dislocations: A Prospective Randomized Study

  • A Randomized, Controlled, Prospective Study Evaluating the Effect of Patellar Eversion on Functional Outcomes in Primary Total Knee Arthroplasty

  • Comparison of Functional Outcome Measures After ACL Reconstruction in Competitive Soccer Players: A Randomized Trial

Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.

Visit the JBJS Knee Spotlight website today.

JBJS Classics: Cuff-Tear Arthropathy Spurred Shoulder Prosthetic Technology

JBJS Classics Logo.pngOrthoBuzz 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 by clicking on the “Leave a Comment” button in the box to the left.

Charles Neer II , a true pioneer in shoulder surgery, coined the term “cuff-tear arthropathy” in 1977. In a landmark 1983 JBJS publication, Dr. Neer, with coauthors Craig and Fukuda (both of whom became internationally recognized experts in shoulder surgery), reported on the pathophysiology and treatment of this previously little-recognized condition that was associated with long-standing massive rotator cuff tears.

Neer’s early work with total shoulder arthroplasty, also reported in JBJS, included a small cohort of patients with cuff-tear arthropathy. In the 1983 article on cuff-tear arthropathy, Neer and his coauthors described the pathologic presentation and treatment with total shoulder arthroplasty, along with a proposed pathophysiologic mechanism. They noted that, although it was a difficult procedure, their preferred treatment was “total shoulder replacement with rotator cuff reconstruction and special rehabilitation.”

Between 1975 and 1983, they surgically treated only 26 patients. Others later recognized that total shoulder replacement was associated with early glenoid failure and recommended treatment with humeral hemiarthroplasty.1 With either approach, success was limited by rotator cuff deficiency and dysfunction. The results were variable, with a small proportion having good outcomes and others achieving some pain relief and limited functional improvement.

Although it was not the first attempt at a reverse shoulder arthroplasty (RSA), Grammont developed an innovative design with improved implant technology and biomechanics to treat massive rotator cuff tears.2 This solved the biomechanical problem that resulted from a deficient rotator cuff and forever revolutionized the care of cuff-deficient shoulders. The Delta 3 prosthesis became available in Europe in the early 1990s but was not widely available in the US until 2004, when it was approved by the FDA.

Initially developed, approved, and used exclusively for cuff-tear arthropathy, early clinical success led to utilization for other conditions with deficient or dysfunctional rotator cuffs, including pseudoparalysis, revision shoulder arthroplasty, acute proximal humerus fractures, fracture sequelae, and chronic glenohumeral dislocations. The results have been so good that the indications have expanded beyond the initial recommendations for use only in elderly low-demand patients. Initial concerns were mollified by the apparent longevity and reported survivorship. Subsequently, there has been such a huge increase in utilization that RSA is approaching 50 percent of the US market share and some of the international market. The implications of expanded indications and increased utilization are yet to be seen.

In 1983, Neer and coauthors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition, as well as advances in shoulder arthroplasty technology.

Andrew Green, MD
JBJS Deputy Editor

References
1. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder
arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3(1):39-46.

2. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993 Jan;16(1):65-8

New RCT Data on Midshaft Clavicular Fractures

Clavicle_Fracture_for_OBuzz.pngThe debate continues as to whether midshaft clavicular fractures are optimally treated surgically or nonoperatively. More data about this clinical dilemma is delivered in the January 18, 2017 issue of JBJS, where Woltz et al. report findings from a multicenter controlled trial that randomized 160 clavicular-fracture patients to receive ORIF with a plate or nonoperative treatment with a sling and physical therapy.

The rate of radiographic nonunion was significantly higher in the nonoperatively treated group after 1 year, but no difference was found between the groups with respect to Constant and DASH scores at any time point—6 weeks, three months, and 1 year. Pain scores and general physical health were marginally better after operative treatment, but only at 6 weeks. However, the rate of second operations for adverse events in the ORIF group was considerable, and after 1 year, implant removal was performed in or scheduled for 16.7% of the operatively treated patients.

Based on these findings and other recent data, the authors “do not advocate routine operative treatment for displaced midshaft clavicular fractures,” although they say early plate fixation may offer advantages for patients who have high demands, high pain scores, or a strong preference for surgery. Based on the fact that “neither treatment option is clearly superior for all patients,” the authors conclude that “the clavicular fracture is preemninently suitable for shared treatment decision-making.”