Tag Archive | JBJS

More Data on Managing Distal Radial Fractures in Old Patients

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

References

  1. Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
  2. 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:

Whence SCFE? More Hints Here

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
JBJS Editor-in-Chief

Predicting ‘Fast,’ ‘Slow Starters’ and ‘Late Dippers’ after THA

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:

  1. Fast Starters (n = 5,290)—steep improvement in OHS during the first 3 postoperative months, after which the OHS leveled out
  2. Late Dippers (n = 463)—more modest improvement in OHS initially, followed by subsequent decline toward the 1-year mark
  3. 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
  • Smoking
  • Age >75 years
  • Obesity
  • 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.

Vancomycin-Soaked ACL Grafts Cut Already-Low Infection Rates

The word “infection” contains 9 letters, but it’s a four-letter word for orthopaedic surgeons. Postoperative infections are complications that we all deal with, but we try hard to avoid them. Infections after elective sports surgeries can have especially devastating long-term consequences. Thankfully, scientific advances such as  improved sterile techniques and more powerful prophylactic antibiotics have helped us decrease the rates of perioperative infections. But more can always be done in this arena.

Baron et al. discuss one additional infection-fighting approach in the December 18, 2019 issue of JBJS, where they report on findings from a retrospective cohort study that looked at 90-day infection rates after >1,600 anterior cruciate ligament (ACL) reconstructions. Specifically, they investigated whether the rates of infection differed when the ACL grafts were prepared with or without a vancomycin irrigant. The average patient age was 27 years old, and all the surgeries (84.1% of which were primary reconstructions) were performed by 1 of 6 fellowship-trained surgeons. The graft was soaked in vancomycin solution in 798 cases (48.7%), while the remaining 51.3% did not use vancomycin.

Baron et al. found that 11 of the reconstructions were complicated by infection within 90 days, but only 1 of those 11 infections occurred in the vancomycin group (p=0.032). After controlling for various confounding factors, the authors found that increased body mass index and increased operative time were also significantly associated with postoperative infection, while age, sex, smoking, surgeon, and insurance type were not.

These results reveal an 89.4% relative risk reduction in postoperative infections after ACL reconstructions when grafts are bathed in vancomycin solution, although the absolute rate of infection among non-soaked grafts (1.2%) was still quite low. Time and more rigorous study designs will tell us whether this is a big step forward in the evolution of infection prevention, but these results should at least prompt further investigation.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Total Ankle Arthroplasty: Maybe Not as Finicky as We Thought?

As the orthopaedic community continues to solve complex issues related to joint replacement, it has become apparent that deformity correction and component positioning are keys to long-term success. In terms of hip, knee, and shoulder arthroplasty, we have progressed throughout the last 50 years with improved functional outcomes and component longevity. Elbow arthroplasty development has lagged somewhat because indications for that procedure are much less common.

Meanwhile, total ankle arthroplasty (TAA) experienced a short-lived decade of enthusiasm in the late 1970s and early 1980s before it became apparent that improved component designs and surgical techniques were needed. Progress with TAA stalled until the late 1990s, but TAA has now become more predictable, and several successful designs are available with reasonable revision rates demonstrated during 10-plus years of follow-up. As with all arthroplasties, component alignment in TAA is critical, and we have therefore assumed that significant preoperative frontal plane deformity is a contraindication for this procedure.

However, in the December 18, 2019 issue of The Journal, Lee et al. challenge that assumption with midterm follow-up data on 146 TAAs that suggest patients with frontal plane deformities >20° should not necessarily be disqualified from having this procedure. In this study, prior to surgery, 107 ankles had moderate frontal plane deformity (5° to <15° of varus or valgus) and 41 ankles had severe deformity (>20° to 35° of varus or valgus). The authors found no difference between these groups in terms of functional outcomes, complications, or implant survival at a mean follow-up of 6 years. Lee et al. conclude that frontal malalignment >20° in patients with end-stage ankle osteoarthritis may not be a contraindication to proceeding with TAA. However, the authors emphasize that concomitant realignment procedures at the time of index arthroplasty (including ligament releases and corrective osteotomies) were much more common in the severe group.

These findings need confirmation from other groups and with longer-term follow-up so that data from lower-volume surgeons can be analyzed and later complications can be investigated. Still, it just may be that ankle arthroplasty is not as finicky as we have been thinking.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Musculoskeletal Basic Science 2019

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 such OrthoBuzz summaries. This month, co-author Philipp B. Leucht, MD selected the most clinically compelling findings from the 40 studies summarized in the December 4, 2019 “What’s New in Musculoskeletal Basic Science.

Muscle Regeneration
–Recent findings about the cellular players in muscle regeneration may allow further development of clinical treatment options for patients with muscle sprains, tears, and loss. Toward that end, Wosczyna et al. established the crucial role of fibroadipogenic progenitors (FAPs, also called mesenchymal stromal cells) in muscle repair and maintenance.1 Using a mouse model, the researchers showed that FAPs are necessary for muscle regeneration by supporting muscle stem cells.

Bone-Brain Crosstalk
–The bone-derived hormone osteocalcin supports development of the musculoskeletal system and the brain. Osteocalcin can regulate anxiety and cognition in adult mice, and Obri et al. postulated that declining levels of osteocalcin may be responsible for the cognitive decline seen in aging.2 This finding may spur investigations into exogenous treatment with osteocalcin to restore brain function.

Tendon Regeneration
–Tendon cells express the transcription factor Scleraxis, which has facilitated the identification of the tendon stem progenitor cell (TSPC). Best and Loiselle identified a Scleraxis-positive cell population in the bridging scar tissue after tendon injury.3 These findings suggest that TSPCs are present in the adult tendon and contribute to the healing response; however, their small number does not result in successful tendon regeneration, but rather in scar formation with interspersed tendon tissue.

–Abraham et al. identified the upregulation of NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) and its downstream targets in tendinopathy-affected human rotator cuff tendons.4 Using a transgenic mouse model in which IKKß (inhibitor of nuclear factor kappa-B kinase subunit beta), a key regulator of inflammation, was overexpressed, they demonstrated the development of tendinopathy in mouse rotator cuff tendons. The deletion of IKKß had a protective effect from chronic overuse.

Bone Regeneration
–Successful bone healing after fracture is highly dependent on the presence and activation of skeletal stem cells. Chan et al. precisely defined the human skeletal stem cell (hSSC), demonstrated the hSSC’s role in human fracture repair, and provided evidence that these cells generate a bone marrow-supportive niche.5 These cells also give rise to bone, cartilage, and stromal progenitor cells.

References

  1. Wosczyna MN, Konishi CT, Perez Carbajal EE, Wang TT, Walsh RA, Gan Q, Wagner MW, Rando TA. Mesenchymal stromal cells are required for regeneration and homeostatic maintenance of skeletal muscle. Cell Rep.2019 May 14;27(7):2029-2035.e5.
  2. Obri A, Khrimian L, Karsenty G, Oury F. Osteocalcin in the brain: from embryonic development to age-related decline in cognition. Nat Rev Endocrinol.2018 Mar;14(3):174-82. Epub 2018 Jan 29.
  3. Best KT, Loiselle AE. Scleraxis lineage cells contribute to organized bridging tissue during tendon healing and identify a subpopulation of resident tendon cells. FASEB J.2019 Jul;33(7):8578-87. Epub 2019 Apr 5.
  4. Abraham AC, Shah SA, Golman M, Song L, Li X, Kurtaliaj I, Akbar M, Millar NL, Abu-Amer Y, Galatz LM, Thomopoulos S. Targeting the NF-κB signaling pathway in chronic tendon disease. Sci Transl Med.2019 Feb 27;11(481):eaav4319.
  5. Chan CKF, Gulati GS, Sinha R, Tompkins JV, Lopez M, Carter AC, Ransom RC, Reinisch A, Wearda T, Murphy M, Brewer RE, Koepke LS, Marecic O, Manjunath A, Seo EY, Leavitt T, Lu WJ, Nguyen A, Conley SD, Salhotra A, Ambrosi TH, Borrelli MR, Siebel T, Chan K, Schallmoser K, Seita J, Sahoo D, Goodnough H, Bishop J, Gardner M, Majeti R, Wan DC, Goodman S, Weissman IL, Chang HY, Longaker MT. Identification of the human skeletal stem cell. 2018; Sep 20;175(1):43-56.e21.

3 Reference Axes Help Ensure Rotational Alignment During TKA

Rotational malalignment of the femoral component during total knee arthroplasty (TKA) is associated with poor outcomes, but how best to assess femoral component rotation intraoperatively remains an unanswered question for arthroplasty surgeons. Now, in the largest study of its kind, Jang et al. conclude in the December 4, 2019 issue of JBJS that combining 3 reference axes is the optimal strategy for ensuring accurate femoral component positioning, sex/ethnic generalizability, and intraoperative efficiency.

The authors compared 5 reference axes commonly used for intraoperative assessment of femoral component rotation by mapping them to >2,100 entire-femur CT scans from patients with nonarthritic knees. Using the surgical transepicondylar axis (sTEA) as the gold-standard reference, Jang et al. found that no single other axis was both highly accurate and relatively immune to ethnic and sex variability. Based on their findings, they instead recommend using a combination of 3 axes—posterior condylar axis externally rotated 3° (PCA + 3° ER), the Whiteside or sulcus line, and the anatomical transepicondylar axis (aTEA)—to ensure rotational alignment.

The authors also suggest a straightforward intraoperative process for using these 3 axes:

  1. Start with the PCA + 3° ER, which most accurately approximates the gold-standard sTEA.
  2. Then use the Whiteside or sulcus line, neither of which is significantly affected by sex or ethnicity.
  3. Finally, palpate for the aTEA to narrow the margin of error.

Citing a limitation to this CT-based study of nonarthritic knees, the authors note that “we could not account for the effects of cartilage wear or other changes caused by degenerative arthritis.”

RCT: Single IV Dose of TXA Is Safe, Effective for TKA

Along the spectrum of early and late adopters in medicine, most orthopaedic surgeons fall in the middle. They wait for science to prove the efficacy and safety of an innovation, carefully review the published studies regarding that innovation, and adopt it if it will improve their patients’ outcomes.

In the December 4, 2019 issue of JBJS, Jules-Elysee et al. compare tranexamic acid (TXA) administered intravenously (IV) versus topically in a double-blinded, randomized controlled trial (RCT) of patients undergoing primary total knee arthroplasty (TKA).  Level-I evidence is rare in the orthopaedic literature, so when a well-performed RCT comes out, we should closely evaluate its findings.

A potent antifibrinolytic, TXA has been shown in multiple studies to decrease blood loss associated with major orthopaedic procedures. However, there are persistent (but not necessarily evidence-based) concerns about its potential to cause thrombogenic complications,  and the safest and most effective route of TXA administration remains an open question.

In this study, the IV group received TXA once before tourniquet inflation and again 3 hours later, along with a topical placebo given 5 minutes before tourniquet release.  The topical group received an IV placebo at the same time intervals as the IV group, along with TXA delivered topically in the wound prior to tourniquet release. The authors found lower systemic levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis) in both groups 1 hour after tourniquet release, but PAP levels remained significantly lower in the IV group (indicating higher antifibrinolytic activity) 4 hours after tourniquet release, which was likely related to the second IV dose of TXA.

The authors also found no between-group difference in systemic or wound levels of prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), indicating there was no increase in thrombogenicity in the IV group.  Interestingly, Jules-Elysee also found that the IV group had significantly higher hemoglobin and hematocrit levels 1 and 2 days after surgery, and those patients had a significantly shorter hospital stay.

Finding no major between-group differences in the mechanism of action, coagulation, or fibrinolytic profile, the authors concluded that a single IV dose of TXA may be the most simple protocol for hospitals to adopt if they are still concerned about TXA safety. Perhaps these Level-I findings will help some of the late adopters get over their fears about the safety of IV TXA.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Meta-Analysis Quality Improving, But Issues Remain

Hip and knee arthroplasty are common procedures worldwide and are increasing annually as demographics change and the technical aspects of these surgeries become more accessible to a broader swath of surgeons. The sheer number of these procedures makes them an appropriate focus for randomized controlled trials (RCTs). The aggregation of RCT data into more powerful statistical frameworks is the job of a meta-analysis.

Not surprisingly, we have seen an increasing number of meta-analyses related to hip and knee replacement published across all major orthopaedic journals during the last two decades. Authors have two common motivations for conducting meta-analyses. The first, to summarize data from carefully conducted RCTs into clinically relevant and important recommendations, is hopefully the most common motivation—and certainly the most justifiable. The second, to merely use previously published data as an analytic exercise to advance one’s academic career without investing the time and effort to do prospective research, is not justifiable, in my estimation.

In the December 4, 2019 issue of The Journal, Park et al. conduct quality and usefulness assessments of 114 published meta-analyses about hip and knee arthroplasty that appeared in 3 major orthopaedic journals (one of which was JBJS) from 2000 to 2017. They document a nearly 4-fold increase in the number of meta-analyses published on these topics when comparing 2000 to 2009 with 2010 to 2017. Based on Oxman-Guyatt Index scores of overall study quality, only 12 of the 114 studies were assessed as high quality, 87 as moderate quality, and 15 as low quality.

Here are some additional findings:

  • The majority of these meta-analyses were not performed in accordance with established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
  • Only 39% of these articles showed the risk of bias.
  • Many of these meta-analyses covered redundant topics within the same year or within a few years of each other.
  • A review by expert attending surgeons of the 24 studies determined to be high quality per PRISMA found that 71% were either clinically unimportant or inconclusive.

It is a positive step to highlight for our readers the important quality issues surrounding meta-analyses, and I agree with James Stoney, who commented on these findings: “The onus is on surgeons to carefully scrutinize meta-analyses…and come to individual conclusions about the quality of the research rather than accept the conclusions at face value.”

But I am discouraged to see the number of problematic meta-analyses that have appeared in our literature, and I suspect most of these quality problems arise from the second, unjustifiable motivation noted above. We need to do better as a research community, as peer reviewers, and as journal editors to improve the quality of published meta-analyses so that we can favorably impact patient care and advance the clinical practice of hip and knee arthroplasty.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Factors Affecting Union after Capanna Reconstruction

Resection of long-bone tumors often leaves large skeletal defects. Since the late 1980s, surgeons have used the “hybrid” Capanna technique—a vascularized fibular graft inlaid in a massive bone allograft—to fill those voids, with good functional outcomes reported. In the November 20, 2019 issue of The Journal of Bone & Joint Surgery, Li et al. report on factors influencing union after the Capanna technique.

The authors radiographically evaluated Capanna-technique reconstructions in 60 patients (10 humeral, 33 femoral, and 17 tibial) and correlated allograft-host union time to the following variables:

  • Patient age
  • Tumor site
  • Adjuvant treatment (e.g., chemotherapy)
  • Previous surgical procedures
  • Defect length
  • Fixation method
  • Fibular viability (assessed with a bone scan 10 days after reconstruction)

They also histologically analyzed a retrieved specimen from one patient.

Among these 60 reconstructions, the mean defect length was 16 cm, and the mean time to union of the constructs was 13 months. The overall survival rate of the constructs was 93% at the latest follow-up.

Multivariate linear regression revealed no correlation between allograft-host osseous union time and patient age, defect length, tumor site, or fixation method. Conversely, devitalization of the transplanted fibular graft, chemotherapy administration, and a previous surgical procedure were associated with a prolonged union time. Histologically, the allograft-host cortical junction was united by callus from periosteum of both the host bone and the fibular graft.

Li et al. conclude that “ensuring patent vascular anastomoses of the transplanted fibula is crucial to prevent delayed or nonunion.” They also suggest that Capanna-technique patients who have any of the 3 “adverse factors” noted above should be treated with extended postoperative immobilization and delayed weight-bearing.