The most common complication arthroplasty surgeons worry about after total knee arthroplasty (TKA) is stiffness, which occurs in a reported 15.98% of cases.1 The notion of TKA patients doing their postoperative physical therapy (PT) on their own at home with a “virtual avatar” gives me pause because it might increase the risk of stiffness. However, if patients could save money, make satisfactory progress in the comfort of their own home, and not experience undue knee stiffness, virtual PT technology would be worth it.
In the January 15, 2020 issue of The Journal, Bettger et al. report on a randomized controlled trial that compared virtual to traditional PT after TKA. The authors hypothesized that virtual PT would cost less and would be clinically noninferior to traditional PT. The FDA-approved Virtual Exercise Rehabilitation Assistant (VERA) studied in this trial uses 3-D technology to track patient movement and an avatar (digitally simulated coach) to assist patients through PT exercises. Virtual PT technology like this not only has the potential to reduce costs (particularly travel costs incurred by patients who live in rural areas), but also to help address current and expected therapist shortages.
There were 143 patients in the virtual PT group and 144 in the traditional PT group. Patients randomized to virtual PT had the technology set up in their home prior to surgery. In addition to avatar-assisted home exercises, virtual PT patients had weekly “video visits” with a human therapist.
Bettger et al. found the median 12-week costs for virtual and traditional PT to be $1,050 and $2,805, respectively. Additionally, at 6 weeks, virtual PT was found to be noninferior to traditional PT in terms of patient outcome measures, knee range of motion, and gait speed. At 12 weeks, virtual PT was found to be noninferior to usual care in terms of pain and hospital readmissions.
I am relieved that virtual PT has the potential to provide cost savings, without apparently increasing the risk of knee stiffness. The cost savings and at-home convenience may be especially important for elderly TKA patients who are living on a fixed income and for whom transportation issues are often vexing. I hope technology like VERA continues to contribute to improved patient satisfaction and easier access to PT.
Jaime L. Bellamy, DO (@jaimelbellamyDO) is an orthopaedic surgeon specializing in hip and knee reconstruction in Fort Bragg, NC and a member of the JBJS Social Media Advisory Board.
- Can administrative data be used to analyze complications following total joint arthroplasty? Clair AJ, et al. J Arthroplasty, 2015;30(9 Suppl):17-20. http://dx.doi.org/10.1016/j.arth.2015.01.060
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, author Michael J. Taunton, MD selected the 5 most clinically compelling findings from the more than 130 studies summarized in the January 15, 2020 “What’s New in Adult Reconstructive Knee Surgery.”
Unicompartmental Knee Arthroplasty (UKA)
—A prospective cohort study of 1,000 Oxford cementless UKAs indicated by standard Kozinn and Scott criteria found that revision-free survivorship at 10 years was 97%. Progression of lateral osteoarthritis and dislocation of the bearing were the most common reasons for revision.1
—Authors of a double-blinded, prospective, randomized study assigned 60 primary total knee arthroplasty (TKA) patients to receive either a continuous adductor canal block or a single-injection adductor canal block with adjuvant agents. They found no between-group differences in pain scores up to 42 hours postoperatively.2
Post-TKA Physical Therapy (PT)
—A prospective, randomized, noninferiority trial demonstrated that 290 post-TKA patients who were randomized to either outpatient PT, unsupervised web-based PT at home, or unsupervised printed-instruction-based PT at home had no difference in knee range of motion or in patient-reported outcomes at 4 to 6 weeks or 6 months postoperatively.3
—In a retrospective review of 29,695 total joint arthroplasties, preoperative penicillin allergy testing led to a 1.19% higher rate of infection-free survival at 10 years, principally by allowing more routine use of the prophylactic antibiotic cefazolin.4
—A retrospective case series found that patients undergoing revision TKA at an age of < 50 years had a survivorship free of re-revision of 66% at 10 years. Regardless of the reason for revision, this population also had a higher risk of mortality than the general population at 10 years.5
- Campi S, Pandit H, Hooper G, Snell D, Jenkins C, Dodd CAF, et al. Ten-year survival and seven-year functional results of cementless Oxford unicompartmental knee replacement: A prospective consecutive series of our first 1000 cases. Knee. 2018 Dec;25(6):1231-7. Epub 2018/08/29.
- Turner JD, Dobson SW, Henshaw DS, Edwards CJ, Weller RS, Reynolds JW, et al. Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial. J Arthroplasty. 2018 Oct;33(10):3160-6 e1. Epub 2018/06/16.
- Fleischman AN, Crizer MP, Tarabichi M, Smith S, Rothman RH, Lonner JH, et al. 2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial. Clin Orthop Relat Res. 2019 Jan;477(1):60-9. Epub 2019/02/23.
- Wyles CC, Hevesi M, Osmon DR, Park MA, Habermann EB, Lewallen DG, et al. 2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J. 2019 Jun;101-B(6_Supple_B):9-15. Epub 2019/05/31.
- Chalmers BP, Pallante GD, Sierra RJ, Lewallen DG, Pagnano MW, Trousdale RT. Contemporary Revision Total Knee Arthroplasty in Patients Younger Than 50 Years: 1 in 3 Risk of Re-Revision by 10 Years. J Arthroplasty. 2019 Jul;34(7S):S266-S70. Epub 2019/03/03.
Rotator cuff tears account for an estimated 4.5 million patient visits per year in the US, which translates into a $3 to $5 billion annual economic burden. Add to that the pain and disability associated with rotator cuff tears, and it’s understandable that many clinical questions arise regarding how best to help patients manage this common condition.
On February 24, 2020 at 8 pm EST, JBJS will host a complimentary 60-minute webinar focused on 2 frequently encountered rotator cuff dilemmas: surgical versus nonsurgical management, and surgical alternatives for irreparable cuff tears that don’t involve joint replacement.
Bruce S. Miller, MD, MS unpacks the findings from his team’s matched-pair analysis in JBJS, which revealed that patients receiving both surgical and nonsurgical management of full-thickness tears experienced pain and functional improvements—but that surgical repair was the “better of two goods.”
Some patients who opt for nonoperative management end up with a chronic, irreparable rotator cuff tear. Teruhisa Mihata, MD, PhD will present findings from his team’s JBJS study, which showed that, after 5 years, healed arthroscopic superior capsule reconstruction in such patients restored function and resulted in high rates of return to recreational sport and work.
Moderated by Andrew Green, MD of Brown University’s Warren Alpert Medical School, the webinar will feature additional expert commentaries. Grant L. Jones, MD will comment on Dr. Miller’s paper, and Robert Tashjian, MD will weigh in on Dr. Mihata’s paper.
The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.
Seats are limited, so Register Today!
One of my residency mentors always stressed that orthopaedic surgeons should be “masters of musculoskeletal anatomy.” During his first lecture each July, he would grill the junior residents on muscle origins and insertions, along with innervations. Knowing safe surgical planes helps us avoid complications from neural or vascular injury and increases the likelihood of a successful orthopaedic procedure. With the increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), it is crucial that orthopaedists understand the anatomical implications of that technique.
One key to a successful DAA hip replacement is adequate visualization, which is aided by retractors. However, malpositioned retractors can cause femoral nerve palsy, a potentially serious neurological complication that can delay postoperative rehabilitation. In the January 15, 2020 issue of The Journal, Yoshino et al. report on a cadaveric study that quantifies the distance between the femoral nerve and the acetabular rim at varying points along the rim. Knowing these precise distances could help surgeons make safer decisions about where—and where not—to place retractors.
The authors dissected 84 cadaveric hips from 44 formalin-embalmed cadavers and measured the distance from the femoral nerve to various points along the acetabular rim by using a reference line drawn from the anterior superior iliac spine (ASIS) to the center of the acetabulum. They found the femoral nerve was closest to the rim (only 16.6 mm away) at the 90° point.
In addition, at 90°, the thickness of the iliopsoas muscle and the femoral length (a probable proxy for size of the patient) were positively associated with increased distance to the nerve. Other anatomic factors such as inguinal ligament length, femoral head diameter, and thickness of the capsule were not associated with the nerve-rim distance.
The degree nomenclature used by Yoshino et al. can be correlated to a clock-face representation of the acetabulum, with the 60° point at the 3 o’clock (anterior) position; the 30° point represents a relatively safe location for placement of the anterior inferior iliac spine retractor (see Figure above).
This important anatomic study can help us improve our mastery of musculoskeletal anatomy—and avoid, if possible, placement of retractors at 90° relative to a line drawn from the ASIS to the center of the acetabulum.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.
Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.
Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.
On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.
It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.
Marc Swiontkowski, MD
In March 2019, OrthoBuzz covered a JBJS study by Rudasill et al. that found a progressively increasing risk of bleeding requiring transfusion among total knee arthroplasty (TKA) patients who had a preoperative International Normalized Ratio (INR) >1. (INR is a standardized measure of how long it takes blood to clot—the higher the number, the longer the clotting time.) These authors also found a significantly increased risk of infection in TKA patients with INR >1.5. and an increased risk of mortality within 30 days of surgery among those with an INR >1.25 to 1.5.
In the January 2, 2020 issue of JBJS, the same team of researchers report findings from a similarly designed NSQIP-based study of patients undergoing total hip arthroplasty (THA). The authors evaluated data from >17,500 patients who underwent a primary THA between 2005 and 2016 and who also had an INR value documented within 2 days prior to joint replacement. Rudasill et al. stratified these patients into 4 groups based on preoperative INRs: ≤1, >1 to <1.25, 1.25 to <1.5, and ≥1.5).
After adjustment, the authors found a significant, independent effect between increased preoperative INR and increased bleeding requiring transfusion and mortality. Specifically, bleeding risk became evident at INR ≥1.25, and patients with INR ≥1.5 were at a significantly increased risk of mortality. The length of hospital stay also increased significantly as INR class increased.
The authors suggest that “current INR targeting [INR <1.5 for elective orthopaedic surgery] may not be strict enough to minimize adverse outcomes for patients undergoing primary total hip arthroplasty.” While admitting that these findings are not likely to change the day-to-day practice of orthopaedic surgeons, the authors say they “may influence preoperative risk stratification for those patients with elevated INR.”
Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.
In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.
At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.
Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
- Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.
Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures:
- “Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
- How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
- Immobilization after Fixation of Distal Radial Fractures
- Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
- Fixation Costs for Distal Radial Fracture
- Plate–Tendon Contact: How Important Is It?
Pediatric orthopaedists have long been searching for anatomic, mechanical, and metabolic causes of slipped capital femoral epiphysis (SCFE). Adolescent obesity has been a recognized SCFE risk factor for 50 years. (Interestingly, high BMI is a consistent risk factor in males, but females who experience SCFE are often thin.) Possible racial risk factors have been examined as well, with no clear conclusions.
Because the incidence of SCFE is relatively low (1 in 10,000 children according to this JBJS Clinical Summary) and the risk of bilaterality is high (in the range of 30% to 40%), it seems likely that anatomic risk factors are at play. In the January 2, 2020 issue of The Journal, Novias et al. home in on the 3-D anatomy of the epiphyseal tubercle (a small, round protuberance thought to stabilize the epiphysis) and peripheral “cupping” of the epiphysis in patients with and without SCFE.
They found a smaller epiphyseal tubercle and more extensive epiphyseal cupping in patients with SCFE compared with normal hips. The authors encourage further investigation of the first finding to determine whether smaller tubercles are a consequence of the slip process or an anatomic variant that predisposes the epiphysis to slip.
A major strength of this study is that all measurements were made by a single observer blinded to the diagnosis of SCFE and other potentially confounding clinical and demographic data. Also, the measurement processes used in this study have been previously validated.
Investigation into the anatomic features of this disease should continue, along with development of minimally invasive, safe, and inexpensive ways to screen for possible anatomic risk factors. The most pertinent clinical goals are to continue evolving minimally invasive methods of epiphyseal stabilization to prevent and/or treat SCFE and to more accurately identify hips at risk of SCFE.
Marc Swiontkowski, MD
Based on ample published data and experience, today’s hip surgeons can give patients who are considering total hip arthroplasty (THA) a good general idea of outcomes to expect. But what if orthopaedists could provide more tailored predictions of THA outcome, and thus help patients more realistically manage expectations?
That is essentially what Hesseling et al. set out to do in their database analysis of 6,030 THA patients gleaned from the Dutch Arthroplasty Register; the findings appear in the December 18, 2019 issue of JBJS. Using the patients’ Oxford Hip Scores (OHS) collected up to 1 year postoperatively and a sophisticated statistical technique called latent class growth modeling, the authors categorized outcome trajectories into 3 categories:
- Fast Starters (n = 5,290)—steep improvement in OHS during the first 3 postoperative months, after which the OHS leveled out
- Late Dippers (n = 463)—more modest improvement in OHS initially, followed by subsequent decline toward the 1-year mark
- Slow Starters (n = 277)—virtually no change at the 3-month mark, followed by an improvement in OHS at 1 year postoperatively
Although the authors were unable to tease out factors that clearly distinguished between late dippers and slow starters, they did identify several factors associated with less-than-fast-starter outcomes:
- Female sex
- Age >75 years
- Anxiety and depression
- American Society of Anesthesiologist (ASA) grade III or IV
- Hybrid fixation (cemented acetabular implant)
- Direct lateral surgical approach
Emphasizing that all 3 subgroups experienced functional improvement after THA, Hesseling et al. nevertheless provide useful information that can help surgeons more accurately estimate which patients might be at risk of a less favorable recovery.