Tag Archive | Orthopedics

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations

The long-term effect of distal radial fracture malunion on activity limitations is unknown. https://bit.ly/2qYgOMh #JBJS

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Effect of Postoperative Mechanical Axis Alignment on Survival and Functional Outcomes of Modern Total Knee Arthroplasties with Cement

Abdel et al. report on the 20-year survivorship of total knee arthroplasty implants that were mechanically aligned (0° ± 3° relative to the mechanical axis) compared with those that were outside that range and considered outliers. https://bit.ly/2uqY77S #JBJS

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JBJS Classics: Biomechanics of the Normal Elbow

jbjsclassics-2016OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

The classic 1981 JBJS article by B.F. Morrey et al. begs to be read carefully, in part because of the name of the lead author. More importantly, this study answers the question that arises with almost every patient with an elbow disorder: Is the achieved range of motion sufficient for activities of daily living? We can answer this question “yes” or “no” after reading this article, and in my own practice, I repeatedly refer to the information provided in it.

Dr. Morrey was an aerospace engineer who worked at NASA for two years before he attended medical school at the University of Texas Medical Branch. After his residency at the Mayo Clinic and after achieving a master’s degree in biomechanics from the University of Minnesota, he joined the staff at Mayo in 1978.

In this article, which integrates Dr. Morrey’s engineering and medical disciplines, he applied a high-tech device of that period (the triaxial electrogoniometer) to answer simple but eternal questions such as what degree of elbow flexion is needed to eat or perform personal hygiene.

It is the nature of human beings to notice particular joint impairments only when they disturb activities of daily living. Patient-reported outcome scores assessing subtle disturbances have recently been published, but we learned from Dr. Morrey’s article that patients with elbow flexion less than 130° will probably be reminded of their elbow problem whenever they try to use a telephone. (With today’s small cellular phones the problem might be even more accentuated.)

There is not much that a contemporary reviewer would criticise if this study were to be submitted today. Yes, the graphics would be nicer, and there would be more than 12 references. Modern computer-aided tools and methods for motion analysis might be more precise (and produce a mass of partially redundant data), but the results would remain essentially the same.

In fact, the question of functional elbow range of motion was revisited in JBJS by Sardelli et al. exactly 30 years after Dr. Morrey’s study appeared. Using modern three-dimensional optical tracking technology, Sardelli et al. found only minimal differences compared to findings in the Morrey et al. study. Only a few contemporary tasks like working on a computer (greater pronation) or using a cellular phone (greater flexion) appeared to require slightly more range of motion than previously reported.

Finally, it is the succinct and pointed results that amaze me whenever I recall the information from Dr. Morrey’s study. All we need to remember are four numbers: 100, 30, 130, and 50. Therein we are reminded that the patient needs to achieve a 100° arc of motion for flexion /extension (from 30° to 130°) and forearm rotation (50° of pronation and 50° of supination).

The authors were able to omit the conclusion sentence we see so often these days: “Further studies are needed…” The question about the minimal range of elbow motion needed to accomplish activities of daily living has been convincingly answered in this article. All residents should read this JBJS classic early, certainly before they examine their first patient with an elbow disorder.

Bernhard Jost, M.D.
JBJS Deputy Editor

Are Ortho Patients Getting Too Many Pain Pills?

narc_usage_2016-10-03Surgeons often prescribe more postoperative pain medication than their patients actually use. That’s partly because there is limited procedure-specific evidence-based data regarding optimal amounts and duration of postoperative narcotic use—and because every patient’s “relationship” with postoperative pain is unique. Nevertheless, physician prescribing plays a role in the current opioid-abuse epidemic, so any credible scientific information about postoperative narcotic usage will be helpful.

The Level I prognostic study by Grant et al. in the September 21, 2016 issue of The Journal of Bone & Joint Surgery identified factors associated with high opioid use among a prospective cohort of 72 patients (mean age 14.9 years) undergoing posterior spinal fusion for idiopathic scoliosis.

Higher weight and BMI, male sex, older age, and higher preoperative pain scores were associated with increased narcotic use after surgery. Somewhat surprisingly, the number of levels fused, number of osteotomies, in-hospital pain level, self-reported pain tolerance, and surgeon assessment of anticipated postoperative narcotic requirements were unreliable predictors of which patients would have higher postoperative narcotic use.

Because the authors found that pain scores returned to preoperative levels by postoperative week 4, they say, “further refills after this point should be considered with caution.” Additionally, after reviewing the cohort’s behavior around disposing of unused narcotic medication, the authors conclude, “We consider discussion of narcotic use and disposal to be an important component of the 1-month postoperative visit…This important educational opportunity could help decrease abuse of narcotics.”

Tai Chi as Effective as PT for Knee OA—Or More So?

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to an Annals of Internal Medicine study investigating the effectiveness of tai chi for treating knee osteoarthritis (OA).Tia Chi.png

We have put men on the moon, but we still have no cure for the osteoarthritis that affects millions of Americans. We try a variety of injections and other conservative measures to help slow the progression of the disease, but at some point arthritis wins. Undaunted, we search for new modalities of easing the disability the disease brings to our patients in hopes of offering an effective treatment.

That is why I read with interest the recent study “Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis” in the Annals of Internal Medicine. I have many patients with debilitating knee arthritis who are not quite ready to embark on a joint replacement until they feel they have exhausted all other options. I have never referred a patient to tai chi, so would this provide another avenue for those patients to explore?

In this trial, 200 patients were randomized to either 24 total tai chi classes or standard physical therapy sessions (12 sessions at the PT office followed by six weeks of monitored home exercise). The primary outcome measure was the WOMAC score. After following the patients for a year, the researchers found that both groups had substantial improvements in their WOMAC scores, along with improvements in four secondary outcome measures:  physical function, quality of life, depression, and medication usage.  The one notable between-group difference was that the tai chi group had significantly greater improvements in depression and quality of life.

It’s clear that increasing physical activity, within reasonable bounds, helps patients with knee arthritis in many ways. Whether that extra activity comes from a tai chi class or a structured physical therapy program may not matter. However, it is possible that the tai chi classes (and other group-based physical activity programs) have social benefits that standard physical therapy does not—and that the patients in the tai chi classes may have benefited substantially from that social connection. Many studies, including those of the Lower Extremity Assessment Project (LEAP) cohort, have shown the power that social and psychological factors can have on a patient’s outcome.  It’s not surprising that similarly positive social effects would be found in patients with knee osteoarthritis.

Still, not everyone with knee osteoarthritis will want or be able to attend a group class, so such a treatment option is not universally applicable. However, these findings should provoke orthopaedic surgeons and payers to consider seriously the social and emotional aspects of OA treatments. Tai chi is certainly not a “moonshot” solution to knee osteoarthritis, but then again, what is?

Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, NC.

JBJS Case Connections—Arthroscopy Solves Ornery Ortho Problems

Avulsed teres minor.gifThe indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. The May 2016 “Case Connections” article springboards from a May 25, 2016 JBJS Case Connector report about an isolated avulsion of the teres minor tendon that was repaired arthroscopically. That unique case is linked to three others from the JBJS Case Connector archive:

  • Arthroscopic treatment of a knee flexion contracture
  • Arthroscopic reduction/fixation of an acetabular rim fracture
  • Arthroscopically assisted medial femoral condyle reduction

As impressive as these minimally invasive solutions are, orthopaedists should always keep in mind that arthroscopy, like any other surgical procedure, is not without its potential complications (see related “Case Connections” article).

JBJS Reviews Editor’s Choice–How Should New Orthopaedic Technology Be Introduced?

Over the past several decades, orthopaedic surgery has enjoyed an explosion in the development of new technologies. These technologies have largely improved the quality of orthopaedic care. The development of new technologies results in both disruptive and nondisruptive evolution and requires that orthopaedic surgeons gain specific knowledge of their appropriate use in clinical practice.

However, despite the advances developed from orthopaedic innovation, many discoveries have been associated with unanticipated adverse events. As an example, the original total hip replacement developed by Charnley featured a 1-piece femoral component with a 22.5-mm head. This was later changed to a larger-diameter head, resulting in increased volumetric wear of conventional polyethylene. In addition, new implants with sharp corners led to cement fractures and the development of so-called cement disease. More recently, metal-on-metal articulations have been associated with metallic particles and ion-induced bone and soft-tissue destruction. Ceramic-on-ceramic articulations may lead to implant breakage, striped wear, and squeaking. There is no question that total hip arthroplasty is an exceptionally successful technology, but there is concern regarding the way in which improvements and innovations gain regulatory approval and surgeon acceptance.

In the May 2016 issue of JBJS Reviews, Goodman et al. discuss the introduction of new technologies in orthopaedic surgery. They review the use of novel biologics and combination products and, in particular, single out platelet-rich plasma for the insufficient clinical evidence to support its use. Moreover, they describe the initial enthusiasm regarding the use of recombinant human BMP-2 for spine fusions but note that a review of clinical trials has revealed that there may be concerns regarding insufficient numbers of patients to assess safety, under-reporting of serious complications, conflict of interest among the investigators, and potential bias.

Goodman et al. address some very simple but nonetheless profound issues. For example, they ask, “How should new technologies be introduced into orthopaedics?” They further ask, “How should a surgeon learn to use new technology?” Perhaps most importantly, they raise the issue of ethical considerations related to the use of new technology.

The future of orthopaedic innovation looks bright. Some have commented that there are too many perceived barriers to gaining regulatory approval of new technologies. Recently, the structure and methodology by which approval of new medical technology is managed across the United States has come under increased scrutiny.

I do not think you can ever be too safe or too careful. This article by Goodman et al. is an excellent review of the issues and considerations. It’s a quick read but leaves plenty of room for thought!

Thomas Einhorn, Editor

JBJS Reviews

Atypical Femoral Fractures: An Update

F2.mediumWe posted our first “Case Connections” article about  bisphosphonate-related atypical femoral fractures (AFFs) one year ago. Since then, JBJS Case Connector has published three additional case reports on the same topic, suggesting that it’s time for a revisit. These three recent cases demonstrate that AFFs can occur despite prophylactic intramedullary (IM) nailing of an at-risk femur, that AFFs can present as periprosthetic fractures, and that men taking bisphosphonates—not just women—can experience AFFs.

CMS to Ease ICD-10 Rules for First 12 Months

The Centers for Medicare and Medicaid Services (CMS) announced this week that it will not deny claims from providers during the first 12 months of ICD-10 implementation based on a lack of code specificity, “as long as the physician/practitioner use[s] a valid code from the right family.” Similarly, CMS will not penalize physicians whose coding lacks ICD-10 specificity when reporting to the Physician Quality Reporting System, Meaningful Use, or Value Based Modifier programs, as long as the submitted code comes from the “correct family.”

In making this joint announcement with the AMA, CMS also said it will establish a “communication and collaboration center,” which will house an ombudsman “to help receive and triage physician and provider issues.” As “ICD-Day” (October 1, 2015) looms, CMS is encouraging small-practice providers to avail themselves of the readiness tools at the “Road to 10” website, which includes a separate section for orthopaedists.

What’s New in Foot and Ankle Surgery: Level I and II Studies

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. Here is a summary of selected findings from Level I and II studies cited in the May 20, 2015 Specialty Update on foot and ankle surgery:

Talar and Calcaneal Fractures

Ankle Instability

  • A prospective randomized study of treatments for severe lateral ankle sprains compared a walking boot with restricted joint mobilization for three weeks with immediate application of a functional brace. No between-group differences in pain scores or development of mechanical instability were found, but the immediate functional-brace group had better function scores and shorter recoveries.
  • A randomized trial comparing neuromuscular training, bracing, and a combination of the two for managing lateral ankle sprains concluded that bracing is the dominant secondary preventive intervention.

Total Ankle Arthroplasty

Ankle and Hindfoot Arthrodesis

  • A pilot RCT comparing B2A-coated ceramic granules with autograft in foot and ankle arthrodesis found that the B2A approach produced a 100% fusion rate, compared with a 92% rate in the autograft group.

Achilles Tendon

  • A Level II study found that weight-bearing cast immobilization provided outcomes that were similar to those of non-weight-bearing cast immobilization in non-operative management of acute Achilles tendon ruptures.

Peripheral Neuropathy

  • In an RCT comparing standard-of-care orthoses with experimental pressure-based orthoses to prevent plantar foot ulcers, the experimental orthoses outperformed the standard ones.
  • A Level I study investigating surgical-site infections after foot and/or ankle surgery found an increased risk of infection associated with concomitant peripheral neuropathy, even in patients without diabetes.