What’s New in Hand and Wrist Surgery 2018
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.
Distal Radius Fractures
—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.1, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.
Scaphoid Fractures
—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.2, which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.
Kienbock Disease
—Lichtman et al.3 introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:
- How old is the patient?
- What is the effect of the disease on the lunate?
- How does the disease affect the wrist?
- What treatments are available?
- What are the patient’s requirements?
Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.
Ulnar Impaction
—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.4 noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.
Prescribing Opioids
—Dwyer et al.5 evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.
References
- Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
- Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
- Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
- Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
- Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.
Excess Opioid Medication Video Summary
Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. https://goo.gl/rZaM3y #JBJS #JBJSVideoSummaries
Excess Prescription Opioids
Postoperative #pain management in orthopaedic surgery accounts for a substantial portion of #opioid medications prescribed in the United States. https://goo.gl/H93hya #JBJS #JBJSInfographics
What’s New in Adult Reconstructive Knee Surgery 2018
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery.
Nonoperative Knee OA Treatment
—Intra-articular corticosteroid injections are commonly administered to mitigate pain and inflammation in knee osteoarthritis (OA). However, a randomized controlled trial of 140 patients found that 2 years of triamcinolone injections, when compared with saline injections, resulted in a significantly greater degree of cartilage loss without significant differences in symptoms.1
Non-Arthroplasty Operative Management
—Knee arthroscopy continues to be largely ineffective for pain relief and functional improvement in knee OA. A randomized controlled trial found no evidence that debridement of unstable chondral flaps found at the time of arthroscopic meniscectomy improves clinical outcomes.
—Cartilage restoration procedures continue to show varying degrees of success. Long-term results from a randomized trial demonstrated no significant differences in joint survivorship and function between patients undergoing microfracture versus autologous chondrocyte implantation (ACI) at 15 years of follow-up. Nearly 50% of patients in both groups had radiographic evidence of early knee OA.
Periprosthetic Joint Infection
—Periprosthetic joint infection (PJI) remains a leading cause of failure following total knee arthroplasty (TKA). Successful treatment requires accurate diagnosis, and alpha-defensin was found to be both sensitive and specific in the diagnosis of PJI. However, it was not significantly superior to leukocyte esterase (LE) in cases of obvious infection.
—Reported rates of reinfection after 2-stage reimplantation for treatment of a first PJI can be as high as 19%. A 3-month course of oral antibiotics following 2-stage procedures significantly improved infection-free survival without complications.2
Post-TKA Complications from Opioids
—Amid ongoing concerns about opioid misuse, two studies3 suggested that preoperative opioid use was found to be an independent predictor of increased length of stay, complications, readmissions, and less pain relief following TKA.
References
- McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M,Ward RJ. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. 2017 May 16;317(19):1967-75.
- Frank JM, Kayupov E, Moric M, Segreti J, Hansen E, Hartman C, Okroj K,Belden K, Roslund B, Silibovsky R, Parvizi J, Della Valle CJ; Knee Society Research Group. The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial. Clin Orthop Relat Res.2017 Jan;475(1):56-61.
- Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty.2017 Sep;32(9):2658-62. Epub 2017 Apr 12.
What’s New in Orthopaedic Rehabilitation 2017
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, Nitin Jain, MD, MSPH, a co-author of the November 15, 2017 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the nearly 50 noteworthy studies summarized in the article.
Pain Management
–Results from a retrospective review1 of patients with noncancer pain highlighted that the risks of long-acting opioids extend beyond overdose, and include increased risks of cardiovascular death and all-cause mortality.
–A randomized prospective trial2 comparing celecoxib, ibuprofen, and naproxen for treating arthritis pain found no significant difference in the hazard ratios for those medications as related to risk of cardiovascular events.
Cost & Quality
–An assessment of a value-improvement initiative3 that examined hip and knee arthroplasty and hip fracture outcomes in a large regional health-care system found reduced costs and improvements in quality of care from 2012 to 2016.
Concussion
–A literature review4 of 7 studies determined that the long-term cognitive and neurogenerative effects of multiple concussions in patients ≤17 years of age remain inconclusive.
Spine
–A randomized trial5 found no difference between anesthetic-only and anesthetic-plus-steroid epidural injections in the treatment of lumbar spinal stenosis.
Shoulder
–A prospective cohort study6 by the MOON Shoulder Group found that the strongest predictor of failure of nonoperative treatment for symptomatic atraumatic rotator cuff tears was lower patient expectations that such treatment would be successful. Pain level, duration of symptoms, and tear anatomy did not predict treatment failure.
References
- Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016 Jun 14;315(22):2415-23.
- Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME,Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V,Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM; PRECISION Trial Investigators. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.
- Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, Johnson S,Gulbransen S, Pelt CE, Horton DJ, Graves KK, Greene TH, Anzai Y, Pendleton RC. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016 Sep 13;316(10):1061-72.
- Yumul JN, McKinlay A. Do multiple concussions lead to cumulative cognitive deficits? A literature review. PM&R. 2016 Nov;8(11):1097-103. Epub 2016 May 18.
- Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD,Bauer Z, Bresnahan BW, Avins AL, Nedeljkovic SS, Nerenz DR, Standaert C,Kessler L, Akuthota V, Annaswamy T, Chen A, Diehn F, Firtch W, Gerges FJ,Gilligan C, Goldberg H, Kennedy DJ, Mandel S, Tyburski M, Sanders W, Sibell D, Smuck M, Wasan A, Won L, Jarvik JG. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014 Jul 03;371(1):11-21.
- Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH,Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC,Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.
By Itself, Spine Surgery Not a Risk Factor for Prolonged Opioid Use
The use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).
Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.
In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”
However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”
The Opioid Epidemic: Consequences Beyond Addiction
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
JBJS Editor-in-Chief
Long-Term Opioid Use Before TKA Raises Risk of Revision
Given the prevalence of opioid prescriptions, many patients present for total knee arthroplasty (TKA) having been on long-term opioid therapy. In the January 4, 2017 edition of The Journal of Bone & Joint Surgery, Ben-Ari et al. determined that patients taking opiate medications for more than three months prior to their TKA were significantly more likely than non-users of opioids to undergo revision surgery within a year after the index procedure.
Among the more than 32,000 TKA patients from Veterans Affairs (VA) databases included in the study, nearly 40% were long-term opioid users prior to surgery. Despite that high percentage, the authors found that chronic kidney disease was the leading risk factor for knee revision among the relevant variables they examined. And even though the authors used a sophisticated natural language/machine-learning tool to analyze postoperative notes, they found no association between long-term opioid use and the etiology of the revisions.
In a commentary accompanying the study, Michael Reich, MD and Richard Walker, MD, note that the study’s very specific VA demographic (94% male) may hamper the generalizability of the findings, especially because most TKAs are currently performed in women. Nevertheless, the commentators conclude that:
- “The study illuminates the value in limiting opioid use during the nonoperative treatment of patients with knee arthritis.”
- “Patients who are taking opioids when they present for TKA could reasonably be encouraged to decrease opioid use during preoperative preparation.”
- “Preoperative use of opioids should be considered among modifiable risk factors and comorbidities when deciding whether to perform TKA.”
What’s New in Orthopaedic Rehabilitation
Every month, JBJS publishes a Specialty Update—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 OrthoBuzz Specialty Update summaries.
This month, Nitin Jain, MD, MSPH, a co-author of the November 16, 2016 Specialty Update on Orthopaedic Rehabilitation, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.
Back Pain
–A prospective cohort study1 evaluating the benefit of early imaging (within 6 weeks of index visit) for patients ≥65 years old with new-onset back pain found that those with early imaging had significantly higher resource utilization and expenditures compared with matched controls who did not undergo early imaging. One year after the index visit, authors found no significant between-group differences in patient-reported pain or disability. They concluded that “early imaging should not be performed routinely for older adults with acute back pain.”
–A randomized clinical trial2 comparing 10 days of NSAID monotherapy with 10 days of NSAIDs + muscle relaxants or opioids for acute nonradicular low back pain found no significant differences across the groups for pain, functional impairment, or use of health care resources. The authors said these findings suggest that combination therapy is not better than monotherapy in this situation, and that the use of opioids in such patients is not indicated.
Rotator Cuff Tears
–A two year follow-up of a randomized trial comparing three treatments for supraspinatus tears (physiotherapy, physiotherapy + acromioplasty, and rotator cuff repair + acromioplasty +physiotherapy) found no significant pain or function differences among the three groups. However, mean tear size was significantly smaller in the cuff-repair group than in the other two.
Pain Medicine
–A meta-analysis3 investigating the use of cannabinoids for managing chronic pain and spasticity concluded that those substances reduced pain and spasticity more than placebo, but the benefits came with an increased risk of side effects such as dizziness, nausea, confusion, and loss of balance.
Psychosocial Factors
–A randomized controlled trial4 comparing a phone-based cognitive-behavioral/physical therapy (CBPT) program to standard education following lumbar spine surgery found that patients in the CBPT group had greater decreases in pain and disability and increases in general health and physical performance.
References
- Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW,Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar17;313(11):1143-53.
- Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
- Whiting PF, Wolff RF, Deshpande S, DiNisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73.
- Skolasky RL, Maggard AM, Li D, Riley LH 3rd., Wegener ST. Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part I: improvement in rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil. 2015 Jul;96(7):1200-7. Epub 2015 Mar 28.
Acute Low Back Pain: Adding Oxycodone to Naproxen Doesn’t Help
As if on cue, a just-published study in JAMA backed up the recent AAOS statement on opioids by finding that neither the opiate oxycodone nor the muscle relaxant cyclobenzaprine (Flexeril) is a helpful adjunct to naproxen for acute, nontraumatic, nonradicular low back pain.
The study randomized 323 emergency-department (ED) patients presenting with low back pain to receive a 10-day course of naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/acetaminophen. The improvement in scores on the Roland-Morris Disability Questionnaire between the time of ED discharge and one week later was similar in all three groups. This finding led Journal Watch Emergency Medicine Associate Editor Daniel Pallin, MD to comment that “prescribing opioids for a condition that evidence-based consensus guidelines warn against can lead to abuse and addiction.”
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