The orthopaedic community worldwide—and especially those of us in the US, the nation most notorious for over-prescribing—has become very cognizant of the epidemic of opioid abuse. Ironically, the current problem was fueled partly by the “fifth vital sign” movement of 10 to 20 years ago, when physicians were encouraged (brow-beaten, in my opinion) to increase the use of opioid medications to “prevent” high pain scores.
Researchers internationally are now pursuing clarification on the appropriate use of these medications. The societal consequences of opioid addiction, which all too often starts with a musculoskeletal injury and/or orthopaedic procedure, have been well documented in the social-science and lay literature. In the May 17, 2017 issue of The Journal, Smith et al. detail an additional consequence to the chronic use of opioid drugs—the negative impact of preoperative opioids on pain outcomes following knee replacement surgery.
Approximately one-quarter of the 156 total knee arthroplasty (TKA) patients analyzed had had at least one preoperative opioid prescription. Patients who used opioids prior to TKA obtained less pain relief from the operation than those who had not used pre-TKA opioids. The authors also found that pain catastrophizing was the only factor measured that was independently associated with pre-TKA opioid use.
To be sure, we need to disseminate this information to the primary care community so they will be more judicious about prescribing these medications for knee arthritis. Additionally, knee surgeons should consider working with primary care providers to wean their TKA-eligible patients off these medications, with the understanding that chronic use preoperatively compromises postsurgical pain relief and functional outcomes.
We have previously published in The Journal the fact that the use of opioids is largely a cultural expectation that varies by country; physicians outside the US often achieve excellent postoperative pain management success without the use of these medications. My bottom line: We must continue to press forward to limit the use of opioid medications in both pre- and postoperative settings.
Marc Swiontkowski, MD
Sport activity continues to increase in priority in modern society. And with a concomitant increase in single-sport focus early in life and near year-round training, the incidence of knee injuries will also continue to increase. Among surgeons and patients, there has been some waning of interest in high tibial osteotomy (HTO) for the most common form of unicompartmental arthritis because results from unicompartmental arthroplasty keep improving, but HTO remains an appropriate choice for patients with very high functional demand.
In the September 21, 2016 issue of The Journal, Ekhtiari et al. report on the findings of a well-conducted systematic review on return-to-work and -sport outcomes of HTO. The authors found that more than four-fifths of patients returned to work or sport, usually within a year after surgery. Approximately four-fifths of patients returned to sport at a level equal to or greater than their preoperative level, and among non-military patients included in the review, 97.8% returned to work at an equal or greater level.
As with most systematic reviews in orthopaedic surgery, the basic concern here is with the quality of the literature that forms the basis of the analysis. The vast majority of studies included in the review were Level IV case series, which leads to concerns about selection and detection bias. Those concerns notwithstanding, a return to sport activity of 87% at a mean follow-up of longer than 5 years is remarkable.
We must recognize that patients who wish to return to sport are the most highly motivated population we serve. HTO should not fall off our radar screen of options for patients with high functional demand and medial compartment arthritis, for they can be some of the most satisfied patients we treat.
Marc Swiontkowski, MD
Attempts by orthopaedists to repair torn human ACLs have failed for the most part, so surgeons now rely almost exclusively on removing the torn ligament and replacing it with autograft or allograft tissue. But now research at Harvard by Martha Murray, MD—a co-author of several JBJS studies—suggests that a torn ACL can be prompted to repair itself.
As Dr. Murray explains in a video, “bridge-enhanced” ACL repair uses stitches and a spongy scaffold injected with the patient’s blood placed between the torn ends of the ACL. The bridge helps healing clots to form and helps surrounding cells grow to rejoin the ends of the ligament. Preclinical studies using this technique have resulted in successful ACL repairs and rates of subsequent knee arthritis that were lower than those seen with reconstruction techniques. Bridge-enhanced ACL repair would also eliminate the need for tissue harvesting in the many patients who choose the autograft reconstruction option.
After reviewing the data from the preclinical studies, the FDA approved the first safety study of this technique in humans, which is now underway.