Botox May Relieve Persistent Tennis Elbow
Lateral epicondylar tendinopathy (“tennis elbow”) that is refractory to the usual interventions of physical therapy/home-directed exercise, ice therapy, corticosteroid injections, and rest is a relatively common but very difficult clinical situation. Patients often become frustrated by the lack of improvement and want something to alleviate the pain and disability. However, the orthopaedic community has been reluctant to recommend surgical intervention except for the most severe cases because the outcomes of this surgery are not as predictable as we would like.
It is within this context that Creuzé et al., in the May 16, 2018 issue of The Journal, present results from a double-blind randomized trial elucidating the impact of low-dose Botulinum toxin injection on this chronic condition. Just over half of the patients treated with the Botulinum toxin injection (n = 29) had a >50% reduction in their initial pain intensity at day 90, and almost 20% felt completely cured. Those results were significantly better than those experienced by the group treated with placebo injections (n = 28).
Kudos to the industry sponsor of this study for supporting the double-blind design, because it removed a significant potential bias that might have otherwise tainted the results. The only fault I can find in the trial is a lack of reporting on the patients’ hand dominance and the magnitude of functional demand on their affected limbs. Before and after treatment, a patient who uses power tools with a dominant and affected limb during a physically demanding job may well have more severe symptoms than a person who works at a computer and whose dominant and affected limb is the “non-mouse” extremity.
It is rare indeed to find a study that blinds the administrator of an orthopaedic intervention, as injections and oral medications are not the most prominent tools in our predominantly surgical armamentarium. The inclusion criteria in the Creuzé et al. study reflected a realistic but difficult patient-enrollment scenario—a minimum of 6 months of symptoms (a mean of almost 19 months) despite previous attempts at all other well-known interventions. The fact that nearly all subjects in both groups had a previous steroid injection into the extensor carpi radialis brevis (ECRB) muscle and continued to experience symptoms confirms the difficulty of these cases and represents what many patients go through in search of an effective treatment.
Furthermore, the fact that only 50% of patients in the intervention group achieved significant pain relief reflects the refractory nature of this condition in many patients. These findings seem to indicate that surgical intervention will remain a necessary component of care for patients with lateral epicondylitis who are not cured by Botulinum toxin injection or other, more common treatment modalities—and that we should pay attention to improving surgical outcomes.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS 100: Knee Hemarthrosis and Achilles Ruptures
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 was 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 two more:
Arthroscopy in Acute Traumatic Hemarthrosis of the Knee
F R Noyes, R W Bassett, E S Grood, D L Butler: JBJS, 1980 July; 62 (5): 687
This paper was among the first to identify the high rate of serious knee injuries among patients with acute traumatic hemarthrosis (ATH). Noyes’ paper showed that 72% of knees with ATH also had some degree of ACL injury. While orthopaedists generally no longer use knee arthroscopy as a diagnostic tool in the setting of ATH, because of this article, they often order MRI when patients present with this acute knee injury.
Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures
K Willits, A Amendola, D Bryant, N Mohtadi, J R Giffin, P Fowler, C O Kean, A Kirkley: JBJS, 2010 December 1; 92 (17): 2767
This multicenter randomized trial was not the first to compare surgical treatment of Achilles tendon ruptures with nonoperative treatment that included early functional range of motion, but it confirmed that in patients treated nonoperatively, early functional treatment is preferable to cast immobilization. Since this paper was published, more than 20 studies investigating Achilles tendon ruptures have been published in JBJS, emphasizing that the search goes on for treatment protocols—surgical and nonoperative—that are effective and relatively free of complications.
JBJS 100: ACL Grafts and Wrist Instability
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 was 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 two more:
Biomechanical Analysis of Human Ligament Grafts Used in Knee-Ligament Repairs and Reconstructions
F R Noyes, D L Butler, E S Grood, R F Zernicke, M S Hefzy: JBJS, 1984 March; 66 (3): 344
This article set the stage for critically analyzing ACL graft choices based on mechanical properties. Several of the grafts these authors studied had poor strength and are no longer used. Subsequent studies now suggest that several grafts are stronger and stiffer than the native ACL, including bone-patellar tendon-bone grafts. While many other aspects of ACL reconstruction continue to be debated, graft strength and stiffness remain a key consideration.
Traumatic Instability of the Wrist
R L Linscheid, J H Dobyns, J W Beabout, R S Bryan: JBJS, 1972 December; 54 (8): 1612
At a time when orthopaedists were focused primarily on osseous anatomy of the wrist, this article emphasized the importance of assessing carpal alignment and realizing the consequences of disrupted carpal ligaments. Most of the parameters for radiographic assessment of carpal alignment in the article are still relevant today.
A Video Approach to Improving Outcomes in Digit Replantation
Arterial and venous reperfusion problems are common causes of failure in digit replantation, so excellent vascular anastomotic technique is crucial during these operations. One way to assess the patency of vascular anastomoses intraoperatively is to estimate refilling velocity with the naked eye. An even better way is described by Zhu et al. in the May 2, 2018 edition of The Journal of Bone & Joint Surgery.
The authors divided their study into two phases. During phase I, they found that a slower refilling velocity ratio (RVR) in 103 replanted digits, calculated with the aid of videos recorded at 1,000 frames per second, was associated with replantation failure. In phase II, the authors applied RVR goals established from phase I to another 79 replanted digits to determine whether the additional objective guidance increased the replantation survival rate compared with historical controls.
Based on phase I results, Zhu et al. set the arterial RVR goal to 0.4 and the venous RVR sum goal to 1.0. Using those goals for guidance, the authors found that the phase II success rate (96%) was significantly higher than that among historical controls (87%). In several phase I cases, intraoperative observations of specialists considered anastomoses to be acceptable, but the high-speed video data revealed that improvements were required.
One downside to obtaining this objective video data about anastomotic quality is that it adds 10 to 15 minutes to operative time. Consequently, the authors cite the need for a “well-designed, randomized, double-blinded clinical trial…to provide stronger evidence of this assessment technique.”
Horseshoes and Total Knee Arthroplasty
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent JBJS article.
The old adage that “close only counts in horseshoes” may also apply to total knee arthroplasty (TKA). Much attention has been paid to coronal alignment during TKA based on conventional wisdom that prosthetic durability and patient function are strongly dependent on that parameter. To re-check that hypothesis, in the March 21, 2018 issue of JBJS, Abdel et al. evaluated the influence of coronal plane alignment on implant survival by analyzing results from a large cohort of patients who underwent primary TKA 20 years ago.
In 2010, Abdel’s group reviewed a consecutive series of 398 primary cemented TKAs done between 1985 and 1990. Knees were divided into 2 groups based on their mechanical alignment as measured using a full-length hip-knee-ankle radiograph. Knees in the “aligned group” (n = 292) were defined as having alignment within 0° ± 3° of the mechanical axis, and knees in the “outlier group” (n = 106) were defined as having alignment >3° in varus or valgus. Implant survival was evaluated based on the need for revision, and the specific indications for revisions were recorded.
In the current study, at 20 years of follow-up, the authors found revision rates that were not significantly different between the same 2 groups—19.5% in the mechanically aligned group and 15.1% in the outliers. Multivariate analysis controlling for patient age and BMI did not demonstrate any implant survivorship benefit for the mechanically well aligned group as compared to the outliers.
This study seems to call into question the dogma that a neutral mechanical axis protects against mechanical failure. The effort, time, and money spent on techniques and devices to improve coronal plane alignment by a few degrees (i.e., computer navigation, custom jigs, and robotics) may not translate into meaningful improvements in patient outcomes.
It is important to note that in this group’s 2010 study evaluating the same cohort, 66% of knees in the outlier group were only 4° shy of neutral and only 12% (13 knees) were >6° off. So, while we should still strive for neutral mechanical alignment, it seems that we may miss the neutral mark by a few degrees without harming our patients.
Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.
Scottish Hip Fracture Treatment Guidelines Improve Outcomes
It is easy, perhaps even fun (in a cynical way), to discredit clinical guidelines and suggested care pathways for certain orthopaedic diseases. They are often nuanced, may require a significant change to our practice that we find impractical, and may seem to offer little benefit over current practices. Why change when our patients do just fine with how we have always treated them? Well, as Farrow et al. clearly demonstrate in the May 2, 2018 edition of JBJS, we should follow these guidelines and patient care pathways in hip fracture patients ≥50 years old because patients have better outcomes when we do.
The authors found that increased adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP), implemented in Scotland in 2014, led to a >3-fold decrease in patient mortality at 1 month and a 2-fold decrease in mortality at 4 months. High levels of adherence to the SSCHFP also led to shorter hospital stays and decreased odds of discharging patients to high-care settings, such as a skilled nursing facility. This cohort study of data collected from >1,000 patients saw only 8% of the initial population lost to follow-up.
Just as importantly, when the authors ran a multiple regression analysis, they found that no single SSCHFP practice or patient variable was as important as following the total SSCHFP protocol. The authors thus conclude that “the impact of the standards as a whole is greater than the sum of the parts and highlights the importance of a multidisciplinary team approach…” In other words, following the protocol helped improve patient outcomes. Period.
Studies like this by Farrow et al. are important and impactful. Practice guidelines and care criteria are developed with careful attention to the evidence base, but we are just starting to see published data on their effect on outcomes. This makes them difficult to accept because we DO have data (at least anecdotal data) supporting our current practices. It is easier to stick to our known current methods than to adopt new ones, however subtle, that require change and have little accompanying outcomes data. Implementing practice guidelines will always be challenging, but having data such as these showing the power of their effect should help make adoption easier.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Click here to read a press release about this study from the University of Aberdeen.
Innovation + Persistence: A Crucial Combination
In the 1970s and 80s, the debate regarding management of clubfoot deformity centered around the location of incisions and how aggressive to be with open releases of hindfoot joints. At that time, Prof. Ignacio Ponseti had been working on his conservative method of clubfoot correction for decades, but his technique was relegated to the sidelines and dismissed as being out of the main stream. Yet he persisted in carefully documenting his results, quietly perfecting his methods, and disseminating his technique by teaching other practitioners. Ever so slowly, the pediatric orthopaedic community migrated in his direction as the complications of the other aggressive surgical procedures, including stiff and painful feet, became apparent.
In the May 2, 2018 edition of The Journal, Zionts et al. report medium-term results from their center with Ponseti’s method. This is a very important study because most of the previously published data regarding mid- to long-term outcomes had come from Dr. Ponseti’s medical center.
The authors found that all 101 patients in the study treated with the Ponseti method had fair to good outcomes at a mean follow-up of 6.8 years. Nevertheless, >60% of the parents reported noncompliance with the bracing recommendations; almost 70% of patients had at least one relapse; and 38% of all patients eventually required an anterior tibial tendon transfer. Increased severity of the initial deformity, occurrence of a relapse, and a shorter duration of brace use were all associated with worse outcomes.
Taken as a whole, the results of this study are comparable to those presented by Ponseti and others from his institution. Even though the Zionts et al. investigation was also a single-center study, the findings are important considering the widespread use of his technique and limited “external” data confirming the validity of this method.
Dr. Ponseti created and refined a highly impactful technique that yields good outcomes in patients with a difficult problem. Although it took decades for his methods to be widely accepted, the lesson here is that what wins the day are careful documentation, thoughtful attention to how best to teach a method, and persistence in the face of skepticism.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
May 24 Webinar – Proximal Humerus Fractures: Improving Outcomes Amid Uncertainty
The incidence of proximal humerus fractures is increasing with the aging of the population worldwide and the associated rise in prevalence of osteopenia and osteoporosis. Anecdotally, the incidence of high-energy proximal humerus fractures in the nonelderly also seems to be on the rise. In cases of complex, comminuted fractures, interest in surgical management has increased due to favorable reported outcomes with locking-plate fixation and reverse shoulder arthroplasty.
Still, many questions remain about how best to manage these fractures in individual patients and by surgeons with varying levels of experience. Beyond the dilemma of operative versus nonoperative management lie many decisions about technical details if surgical treatment is selected.
On Thursday, May 24, 2018 at 8:00 pm EDT, the Journal of Shoulder and Elbow Surgery (JSES) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar—co-moderated by JSES Editor-in-Chief Bill Mallon, MD and JBJS Deputy Editor Andy Green, MD—that will address some of these questions.
JSES co-author Mark Frankle, MD will discuss findings from a recently published decision analysis that found experienced shoulder surgeons agreeing on optimal treatment for these fractures only 64% of the time. Patients may have poorer range-of-motion outcomes in scenarios where uncertainty exists.
Brent Ponce, MD, co-author of a cadaveric study published in JBJS, explains how his research team concluded that medial comminution is a predictor of poor stability in proximal humerus fractures treated with locking plates, but that stability may be improved in such cases (and in non-comminuted fractures) when fixation includes the calcar.
After each author’s presentation, an additional shoulder-fracture expert will add clinical perspective to these important findings. Xavier Duralde, MD will shed additional light on Dr. Frankle’s paper, and Joaquin Sanchez-Sotelo, MD will comment on Dr. Ponce’s paper. During the last 15 minutes of the webinar, a live Q&A session will provide the audience with the opportunity to question the panelists about the concepts and data presented.
Seats are limited, so Register Now.
More Progress in Preventing Secondary Fragility Fractures
How well do fracture liaison services (FLSs) work in terms of patients who’ve had a fragility fracture receiving a recommendation for anti-osteoporosis treatment? Very well, according to findings from an analysis of more than 32,000 patients by Dirschl and Rustom in the April 18, 2018 edition of The Journal of Bone & Joint Surgery.
A fracture liaison service is a coordinated, multidisciplinary model of care designed to reduce the risk of future fractures among patients who’ve sustained a primary fragility fracture. (Click here for another recent JBJS article about the FLS model.) The American Orthopaedic Association (AOA) has been a major proponent of the FLS model, and it is a cornerstone of the AOA’s “Own the Bone” national quality-improvement program.
Dirschl and Rustom found that between 2009 and 2016, at 147 sites participating in an FLS through Own the Bone, 72.8% of 32,671 patients initially evaluated for a fragility fracture received a recommendation for anti-osteoporosis treatment. That’s a vast improvement compared with previous reports that indicate only 20% of patients with a fragility fracture received either an osteoporosis evaluation or treatment. In this current study, a sedentary lifestyle and having a parent who had sustained a hip fracture were the patient factors associated with those most likely to receive a recommendation for treatment.
OrthoBuzz editors were surprised to read that anti-osteoporosis treatment was initiated in only 12.1% of the patients in this study. When we asked JBJS Editor-in-Chief Marc Swiontkowski, MD for a further explanation, he noted that the study captured data only from the initial post-fracture encounter between patients and FLS clinicians. The percentage of patients initiating treatment would have been much higher, he said, if the data had included those who followed up their initial FLS evaluation with a primary care physician. He also remarked that some people are dissuaded from taking an FDA-approved prescription anti-osteoporosis medication by the disproportionate focus on side effects that patients read in social media and the lay press. And there are some patients for whom prescription anti-osteoporosis drugs are truly contraindicated.
But with an estimated 2 million people in the US sustaining a fragility fracture each year, these results indicate substantial progress in practices that will prevent secondary fractures.
Click here for a listing of upcoming Own the Bone events.
Childhood Toe-Walking: Usually a Transient Condition
Parenting is a lot like medicine. Parents seek to “fix” their children, and physicians seek to “fix” their patients. However, sometimes the best “fix” is to observe closely, do nothing, and let nature take its course. That’s the main conclusion of the study by Engstrom et al. in the April 18, 2018 edition of JBJS. The authors set out to document the natural history of idiopathic toe-walking to determine how often the condition resolves without intervention.
After analyzing a cohort of more than 1,400 children, the authors found that 63 (5%) had been toe-walkers at some point as a toddler—but that almost 80% of those children spontaneously ceased being toe-walkers by the time they were 10 years of age. However, the authors found that children with ankle contractures before age 5 were unlikely to spontaneously cease toe-walking and would benefit from early surgical intervention. This study also demonstrated a correlation between neurodevelopmental comorbidities and toe-walking. Although 4 of the 8 children who still toe-walked at 10 years of age had received a neurodevelopmental diagnosis between the ages of 5.5 and 10 years, the authors state that “even in this subgroup of children, the idiopathic toe-walking seems, for the majority of children, to be a transient condition.”
Taken as a whole, this Level-I prognostic study provides relatively clear treatment pathways for clinicians and parents to follow when a child presents with toe-walking. The findings can be used to help calm the fears of parents regarding their child’s development while also giving surgeons the confidence to treat the majority of these children with observation unless there is a contracture of the calf musculature.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
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