The dangers of chronic opioid use have rightly been at the forefront of orthopaedic practice considerations in recent years. The widespread use of regional anesthesia and periarticular-injection cocktails, targeted NSAID utilization, and strict limitations on opioid use have become standard approaches for postoperative pain management.
With the availability of cannabinoids in numerous state jurisdictions, attention has now turned to the potential of these compounds to enhance patient comfort in the postoperative period. However, as we contemplate their use, it’s imperative that we also evaluate the impact of these compounds on clinically important outcomes such as bone-healing and fusion. The track record of nicotine, NSAIDs, and other compounds in terms of the impact on bone-healing is enough to suggest caution.
In the June 2, 2021 issue of JBJS, Yun et al. provide new insight into this topic. Specifically, they evaluated the impact of cannabinoid receptor agonist WIN55 on osteogenic differentiation in vitro and bone regeneration and spinal fusion in a preclinical rat model.
They found that WIN55 had no adverse impact on osteogenic differentiation of primary bone marrow stem cells in vitro. As noted by the authors, “mRNA expression levels of Runx2 and Alp were similar among cells treated with vehicle alone and WIN55. Likewise, exposure to WIN55 did not inhibit ALP [Alkaline phosphatase] activity or bone matrix mineralization.”
In addition, no adverse impact of WIN55 on spinal fusion or bone regeneration was found. Forty-five rats (15 per group) underwent L4-L5 posterolateral spinal fusion with bilateral placement of collagen scaffolds soaked with rhBMP-2. The rats were treated with vehicle alone or 0.5 or 2.5 mg/kg WIN55 by way of daily intraperitoneal injections for 5 days. Radiography, manual palpation-based fusion scoring, microCT, and histology were used for assessment. No significant differences among the groups in the mean fusion score, fusion rate, and new bone volume were demonstrated.
These findings are intriguing, and such research helps set the stage for carefully designed in vivo research projects, eventually moving toward randomized controlled trials, before recommending widespread use of cannabinoids for post-surgical pain management.
Marc Swiontkowski, MD
Terminology is important in orthopaedics. When teaching, for instance, we stress the need for trainees to be able to articulate what a radiograph is showing using descriptive terms and classification systems.
Over the years, “multiligamentous knee injury” (MLKI) and “knee dislocation” have increasingly been used interchangeably within the orthopaedic vernacular, in part because of the high energy required to sustain such injuries, but also because of the potentially devastating complications that can be associated with both.
Kahan et al. sought to better characterize these injuries and their associated complications in a study now reported JBJS. They retrospectively evaluated cases treated at their Level-I trauma center between 2001 and 2020.
A total of 123 patients with MLKI were included in the analysis: 45 patients with and 78 patients without a documented knee dislocation. MLKI was defined as disruption of at least 2 of the following: the anterior cruciate, posterior cruciate, medial collateral, and lateral collateral ligaments. Cruciate ligament injuries and isolated injuries of the superficial medial collateral ligament were not included unless there was disruption of the posteromedial corner, semimembranosus, or medial patellofemoral ligament, indicating a more extensive medial-sided injury.
The investigators found that medial-sided injuries were more common in the dislocation group (53% vs 30%; p = 0.009), and the dislocation group had higher rates of peroneal nerve injury (38% vs 14%; p = 0.004) and vascular injury (18% vs 4%; p = 0.018). Of the 11 total patients with a vascular injury, 8 (73%) were in the dislocation group; 10 of the 11 underwent a vascular surgical procedure.
Not all cases of MLKI are a result of a knee dislocation, and in this adequately powered study, there were differences in the injury pattern and associated injuries between those with and without true dislocation. It is important to note that, although higher rates of neurovascular injury were seen in the dislocation group, such events also occurred in the group without dislocation, so a high index of suspicion must be maintained with these complex injuries. As the authors suggest, it may be better to consider cases of knee dislocation a subset of MLKI with the potential for increased neurovascular compromise.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent article in Ultrasound in Medicine and Biology by Bekhet et al., this commentary comes from Christopher Dy, MD, MPH.
In their study from Cairo, Egypt, Bekhet et al. report their experience using ultrasound (US) to examine tendon integrity in the setting of suspected flexor tendon injury. A single musculoskeletal radiologist performed diagnostic US in 35 patients with trauma to the ventral surface of the hand or wrist; a total of 50 tendons were evaluated, with zone-II injuries being the most common.
US correctly identified all complete tendon disruptions, with no false positive or false negative results. US identified partial tendon injuries with 98% accuracy, with 1 false positive result and no false negatives. In comparison, clinical examination alone had a diagnostic accuracy of 88%. The diagnostic performance of US in this study is impressive, and suggests that US may have a role in the diagnostic workup of patients with suspected flexor tendon injury.
While many surgeons still rely on physical examination, it is clear that clinical assessment alone is imperfect. An accurate, objective diagnostic test is desirable for determining the need for (and extent of) surgical treatment as well as in counseling patients. MRI has been suggested to fill this role, but it can be expensive and time-consuming. US is a natural alternative, but its usage in most practice settings (including North America) has been limited because of its operator-dependent nature. That is a key acknowledgment made by the authors of this study, which limits the generalizability and impact of their findings. As only 1 highly specialized radiologist performed the US examinations in the study, it is unclear whether US performed by a less-experienced sonographer would provide the level of detail needed to directly affect clinical management.
Further validation studies (both within the authors’ institution as well as in other centers) would provide important information to determine the utility of US in accurately diagnosing the location and extent of flexor tendon injuries.
In my practice, if there is doubt regarding the integrity of a flexor tendon, I have used US performed by a musculoskeletal (MSK) radiologist or a US-trained physiatrist to provide diagnostic clarity. Admittedly, if the US results do not match my clinical impression, I will either order an MRI or discuss surgical exploration with the patient. This bias in my decision-making process clearly demonstrates my belief that further work is needed to show that US can be used accurately and reliably. While the findings of Bekhet et al. are intriguing, the single-sonographer limitation leads me to question the external validity of their findings. Because of this, the findings of this study are not practice-changing. But I hope to be proven wrong!
Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.
In the May 5, 2021 issue of JBJS, Tomizuka et al. report the results of mechanical testing in which they quantified the loss of supination and flexion strength after a series of surgical releases designed to simulate traumatic avulsions of the short and long head of the distal biceps tendon.
Reflecting on the clinical implications of their study, the authors note:
Partial tears of the distal biceps tendon can cause substantial disability, yet the mechanical effect of such ruptures is not fully understood. This study showed that a simulated complete short-head tear significantly decreased (p ≤ 0.043) the supination moment arm by 24% in pronation and 10% in neutral.
A mechanical case can be made for early repair of a partial distal biceps tendon tear when the rupture is ≥75% of the distal insertion site.”
Click here for the full JBJS report.
A JBJS Clinical Summary on distal biceps tendon rupture can be found here.
Thirty-eight patients with schizophrenia were compared with 170 geriatric patients without schizophrenia who underwent a surgical procedure for a hip fracture.
Read the full article here.
The worldwide incidence of mental illness seems to be on the rise—and along with it a widespread recognition that this “epidemic” should receive at least as much attention as other health conditions. At the same time, many societies have transitioned to noninstitutionalized care for patients with severe mental health diagnoses. This parallel phenomenon has resulted in more individuals with mental and emotional challenges being cared for by their families and communities.
Orthopaedic surgeons are often asked what the prognosis is for recovery in a patient with a substantive mental health diagnosis, but only a few scholarly attempts have been made to answer that question. In the May 5, 2021 issue of JBJS, Ng et al. provide meaningful data regarding the concomitant diagnosis of schizophrenia among patients in their early 70s who experienced a hip fracture. One-year post-treatment results from this cohort study showed no differences in mortality or surgical or medical complications between patients with and matched patients without schizophrenia. These good-news findings are largely indicative of the high level of care hip fracture patients receive in the authors’ institution, which includes close collaboration among surgeons, geriatrists, physical therapists, and psychiatric clinicians.
However, the 1-year functional outcomes, as measured with the Modified Barthel Index, were worse in the cohort with schizophrenia. I think this is probably related to the difficulty of encouraging patients to participate in standardized rehabilitation processes, challenges associated with self-care, and potentially less-than-optimal social support.
We certainly need more research into determining the best peri- and post-treatment care for orthopaedic patients with severe mental health issues. Ideally, future investigations of these questions will focus on interactions between mental health professionals and surgical and rehabilitation teams. It is my hope that this study by Ng et al. will stimulate that type of research.
Click here for a downloadable Infographic summarizing this study.
Marc Swiontkowski, MD
I was once told that if you don’t have any cases with complications, you either aren’t operating enough or aren’t following your patients. Although we in the orthopaedic community make every effort to minimize the occurrence of patient complications, one that remains difficult to eradicate is periprosthetic joint infection (PJI), which is a leading cause of revision total knee arthroplasty (TKA). The welfare of our patients requires successfully addressing this potentially devastating outcome, but reimbursement for these complex cases has decreased over the past decade.
In the upcoming issue of JBJS, Jella et al. offer insight on temporal trends in Medicare physician reimbursement for revision TKA. They queried the Medicare Physician Fee Schedule Look-Up Tool for pricing information corresponding to 1 and 2-stage revision TKAs and used monetary data from Medicare Administrative Contractors to calculate nationally representative means. The authors evaluated aseptic revision of 1 component, 1-stage revision (aseptic or septic), and both the first and second stages of a 2-stage septic revision.
They found that, from 2002 to 2019, there was a mild increase in the physician fee for each CPT code, with the exception of that for second-stage implantation. However, after adjusting for inflation, total Medicare reimbursements declined for both septic and aseptic revision TKAs (between 23% and 33%), with a significantly greater decline observed for septic revision.
The authors also found that Medicare spending on aseptic revision TKA nearly doubled from 2004 to 2017, while spending on septic revision TKA increased only slightly. They note that a main driver of the discrepancy between septic and aseptic revision may be the reimbursement for the second stage of the former procedure using CPT 27447 instead of a revision procedure code (27487).
We know that an increase in revision TKAs (both septic and aseptic) is expected as the number of primary TKA procedures continues to rise. If reimbursement doesn’t keep pace, it is likely to drive certain surgeons away from tackling the sometimes difficult cases, in turn, leaving our patients with fewer available resources when faced with PJI.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from James Blair, MD, in response to a recent edition of the OrthoJOE podcast.
Geriatric hip fractures are among the fastest growing subset of injuries that orthopaedic surgeons treat. Often these injuries are the first objective signs of osteoporosis. While the surgical treatment of these fractures continues to improve, orthopaedic surgeons may be neglecting their role in triggering investigations into the underlying bone health of these patients.
A recent insurance database analysis by Sara Cromer, MD, presented at the Endocrine Society’s 2021 Annual Meeting, demonstrated a substantial drop in the use of bone-directed medications over the past decade, despite the rise in the number of osteoporotic-related fractures. It is unclear why this trend has occurred, but the main concern is that new diagnoses of osteoporosis are being overlooked.
This concern arose during a recent OrthoJOE podcast focused on distal radial fractures. OrthoEvidence Editor-in-Chief Dr. Mo Bhandari alluded to the confusion over who is responsible for bone-health intervention during treatment of a fragility fracture: the inpatient orthopaedic surgery team, the hospitalist, or the patient’s family physician or internist. “The thought is that someone is going to manage this,” Dr. Bhandari states. “Everyone is looking at everyone else, and it’s not happening.”
In fragility-fracture cases, JBJS Editor-in-Chief Dr. Marc Swiontkowski emphasized the importance of orthopaedic surgeons initiating investigations into their patients’ bone quality with evaluations of vitamin D, ionized calcium, and parathyroid and thyroid hormone levels. “We are failing miserably at this,” Dr. Swiontkowski laments, recalling seeing 3 elderly patients in a single day with a hip fracture that was preceded by a distal radial fracture a decade earlier–with no bone-health investigation ever performed at that time.
Initiatives like the American Orthopaedic Association’s (AOA’s) “Own The Bone” program try to raise awareness of our broader responsibility as orthopaedic surgeons when treating osteoporotic fractures such as those of the proximal femur, distal radius, and vertebrae. Drs. Bhandari and Swiontkowski strongly believe that the orthopaedic surgeon must claim ownership of their patients’ bone health, not necessarily by medically managing such cases, but by initiating a dialog with the patient’s primary care physician and/or rheumatologist/endocrinologist.
Click here to find out more about the AOA’s “Own The Bone” program.
James A. Blair, MD is the Director of Orthopaedic Trauma at the Medical College of Georgia at Augusta University and a member of the JBJS Social Media Advisory Board.