The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.
A large retrospective cohort study analyzing nearly 21,000 patients who underwent primary total hip arthroplasty (THA) found that the 61% who received general anesthesia were much more likely to experience an adverse event within 30 days than the 39% who received spinal anesthesia.
Among the adverse events analyzed, the increased risks associated with general anesthesia were more than five-fold for prolonged postoperative ventilator use and cardiac arrest, and more than two-fold for unplanned intubation and stroke. These findings are generally consistent with those of prior research into this question, but the authors say this is “the largest study to date” looking at the comparison.
The authors analyzed data from the National Surgical Quality Improvement Program (NSQIP), and they found that the increased adverse-event risk with general anesthesia held throughout all ranges of preoperative comorbidity. They therefore contend that while many previous studies have found advantages for spinal anesthesia in “medically complex” joint-replacement patients, “this study indicates that these benefits may also extend to patients with fewer medical comorbidities.”
Despite these findings, the authors stress that spinal anesthesia is not risk-free, with the potential (albeit low) for permanent injury to the spinal cord or spinal nerves. They also note that their 30-day postoperative analysis did not capture patient-centered metrics such as postsurgical pain or longer-term functional outcomes.
A randomized study of 80 postmenopausal women with mild knee osteoarthritis found that those assigned to a supervised progressive-impact exercise program (including jumping and change-of-movement exercises) thrice weekly for a year experienced more biochemical improvements in their patellar cartilage, as determined by MRI T2 relaxation time, than those in a non-intervention control group. The exercise group also saw greater improvement in muscle strength and aerobic capacity, while patient-reported KOOS-score changes were similar in both groups.
Although many clinicians deem high-impact activity to be contraindicated in this population, this study suggests that postmenopausal women with mild knee OA can, under the supervision of a physical therapist, be encouraged to include high-impact exercises in their fitness regimen.
In the February 18, 2015 issue of The Journal, Rohner et al. report their experience with knee arthrodesis using an intramedullary rod as the definitive treatment for failed total knee arthroplasties (TKAs) related to infection. They report the results for 26 patients treated between 1997 and 2013 who had undergone an average of 6 ±3 knee procedures prior to arthrodesis.
The outcomes for this cohort of patients are sobering. Persistent infection requiring additional surgery remained in 50% of the patients. The health-related quality-of-life measures and functional outcomes were abysmal, and 73% reported persistent pain at greater than 3 on the VAS. Obesity, high blood pressure, and diabetes were strong predictors of reinfection.
Many of us have taken comfort that knee fusion, by whatever surgical technique, is a reliable “bail out” for the problem of recurrent infection following revision of a loose or infected TKA. Nevertheless, any surgeon who has followed a patient with a knee fusion is fully aware of the functional disability associated with the stiff knee. Difficulties using public transportation and impaired sitting are just two inconveniences that these patients express unhappiness about.
Despite its retrospective design and relatively small number of cases, this report may cause the knee-reconstruction community to reconsider knee arthrodesis and instead attempt further staged revisions of the knee prosthesis. It may even prompt a slightly earlier move toward recommending trans-femoral amputation. It certainly will stimulate further research into infection prevention and into developing more predictable approaches for revising infected TKA prostheses.
Marc Swiontkowski, MD
We stumbled upon three recent studies of knee osteoarthritis (OA) that shed interesting new light on a condition that all orthopaedists deal with.
–A “network” meta-analysis in the Annals of Internal Medicine looked at 137 randomized trials of OA treatments comprising more than 33,000 participants. Treatments analyzed included acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) steroids, IA hyaluronic acid, oral placebo, and IA placebo. For pain, all active treatments except acetaminophen yielded clinically significant improvement. IA hyaluronic acid came out on top for pain relief, although the authors postulated that an “integrated” placebo effect may explain that finding.
–A cost-modeling study in Arthritis Care & Research, co-authored by JBJS Deputy Editors for Methodology and Biostatistics Jeffrey Katz, MD and Elena Losina, PhD, revealed that the per-patient cost attributable to symptomatic knee OA over 28 years is $12,400. Any expanded indications for total knee arthroplasty (TKA) and a trend toward increased willingness among patients to undergo knee surgery will increase that cost. The researchers found that patients tried nonsurgical regimens for a mean of 13.3 years before opting for TKA, and they stress the need for more effective nonoperative therapies for knee OA.
–Wine drinkers, rejoice! A retrospective case-control study in Arthritis Research & Therapy found that people who drank four to six glasses of wine per week were less likely to develop knee OA than nondrinkers. Meanwhile, beer drinkers may want to switch to wine. The same study found that people who drank 8 to 19 half-pints of suds per week had an increased risk of developing knee OA. Researchers found no link between total alcohol consumption and risk of knee OA. The authors postulate that the resveratrol found in wine may be chondroprotective, and that the linkage between beer and increased blood levels of uric acid may explain the opposite finding. It’s wise to remember that studies investigating one or two dietary items can be less-than-definitive because they are usually retrospective, subject to recall bias, and do not account for complex interactions among many nutrients.
When most laypeople—and perhaps some orthopaedists—see a child with a fractured arm or leg bone poking through a skin wound, they probably think surgery is inevitable. But a recent study in the Journal of Children’s Orthopaedics, co-authored by JBJS Deputy Editor for Pediatrics Paul Sponseller, MD, found that among 40 pediatric patients with nonoperatively treated type I open fractures (where the bone communicates with a clean wound less than 1 cm in length), there were no infections, and all patients eventually had complete bony union. The nonoperative treatment included irrigation and debridement followed by closed reduction and casting, and all patients were discharged home from the ED. The only complication was a small retained foreign body walled off by a non-infected granuloma that was removed uneventfully in the clinic four weeks after the initial procedure.
In a news release, Dr. Sponseller said, “Our findings indicate that when it comes to simple, clean open breaks, which are very common in kids, a minimalistic ‘clean, set the bone and watch’ approach could be just as effective as more aggressive surgical treatments.” The limited number of patients in the study did not power it sufficiently to draw ironclad conclusions, and the authors concluded that “additional prospective randomized clinical trials are needed to make a definitive level I recommendation regarding nonoperative management.”
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 randomized studies cited in the January 21, 2015 Specialty Update on adult reconstructive knee surgery:
Minimizing Blood Loss
–A randomized study of 101 patients undergoing total knee arthroplasty (TKA) found that those receiving topical tranexamic acid (TXA) intra-articularly at the end of surgery had less blood loss and better postoperative hemoglobin levels than those who received a placebo.
–A randomized study of 50 TKA patients and 50 people undergoing total hip arthroplasty found that those receiving TXA had a significantly smaller decline in postoperative hemoglobin levels and needed 39% fewer units of transfused blood than a group that received normal saline solution.
–A randomized study of 126 patients who underwent denervation or not after TKA with unresurfaced patellae found that the denervation group had better pain scores at three months and higher satisfaction and better range of motion at two years.
–Two randomized studies evaluated the impact of patellar eversion versus lateral retraction/subluxation for joint exposure. One study (n=117) found no between-group differences in quadriceps strength at one year, and the other (n=66) found no between-group differences in pain scores or flexion at three months and one year.
Most of the implant-design studies summarized in this Specialty Update can be summed up as “no difference.” Specifically,
–Three randomized studies attempting to evaluate high-flexion TKA designs (n=74, n=278, and n=122) caused the authors of the update to suggest that “the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes.”
–A randomized study of 124 patients found no differences in maximal post-TKA flexion or functional scores between a group that received a bicruciate-substituting implant and one that received a standard posterior-stabilized design.
–A randomized trial of 34 patients who received prostheses with either highly cross-linked polyethylene or conventional polyethylene found no differences in wear-particle number, size, or morphology after one year.
–A 4- to 6.5-year follow-up study of 56 patients who received either mobile or fixed bearings during TKA found that the mobile-bearing group had greater mean range of motion, but there were no between-group differences in satisfaction or functional scores.
Instrumentation and Technique
–A randomized study of 47 patients whose surgeons used either customized cutting blocks or traditional instruments found no differences in clinical outcomes or mean component alignment. Moreover, surgeons abandoned customized blocks in 32% of the cases because of malalignment.
–A randomized study of 129 patients whose surgical approach was either medial parapatellar or subvastus, all of whom were managed with minimally invasive techniques, found no differences in pain, narcotic consumption, functional outcomes, and Knee Society Scores at postoperative times ranging from three days to three months.
Postoperative Care and Pain Management
–A trial among 249 post-TKA patients who received either one-to-one physical therapy (PT), group-based PT, or a monitored home program found no difference in outcomes at 10 weeks and one year.
–A randomized study of 160 post-TKA patients investigating the effect of continuous passive motion (CPM) machines led the study authors to conclude that CPM is neither beneficial nor cost-effective.
–A small randomized study of pain-management protocols found that a “multimodal” approach that included peri-articular injection led to less pain, less narcotic use, and higher satisfaction for up to six weeks after surgery than a patient-controlled analgesia approach.
–A three-way randomized pain-management study of 100 patients led study authors to recommend against posterior capsule injections and to conclude that “a sciatic nerve block [for TKA] has a minimal effect on pain control.”
–A three-way randomized study of 120 TKA patients found that those receiving preoperative dexamethasone and ondansetron had less nausea, shorter hospital stays, and used less narcotic medication than those who received ondansetron alone. “Dexamethasone should be part of a comprehensive total joint arthroplasty protocol,” the study authors concluded.
Last year, we reported on orthopaedic surgeon compensation data from Medscape. This year, we take a look at orthopaedist compensation numbers (base salary, plus incentives and discretionary compensation) from the American Medical Group Association (AMGA).
According to the AMGA’s 2014 Medical Group Compensation and Financial Survey, median orthopaedic surgeon compensation in 2014 was $538,123, up 2.5% from 2013. Among the eight surgical specialties surveyed for compensation data (neurosurgery was not included), orthopaedists came in second to cardiac/thoracic surgeons (whose median was $569,073, up 8.2% from 2013).
Compensation data from orthopaedic subspecialists revealed the following medians, from lowest to highest:
Foot and Ankle $505,606
Sports Medicine $549,048
Joint Replacement $563,896
Readers should keep in mind that two-thirds of the more than 950 orthopaedists who responded to the compensation portion of the AGMA survey were from group practices comprised of more than 150 physicians. Data from those individuals may not represent the compensation realities for orthopaedic surgeons in independent or smaller group practices.
The Health of America, a new report from the Blue Cross Blue Shield Association (BCBSA), found that the amounts charged by hospitals for hip- and knee-replacement surgeries in 64 US geographic markets vary wildly within and between markets.
The report focused on hip and knee replacements because those are among the fastest-growing medical interventions in the US. The report cited a June 4, 2014 JBJS study stating that between 1993 and 2009, primary knee replacements more than tripled, and primary hip replacements doubled.
The BCBSA report found that within-market cost variation for knee replacements exceeded $18,701 in 16 of the 64 markets analyzed. Twenty-two of the markets studied had a greater than $17,301 variation for hip replacements. The dubious distinction for highest variation within a market went to Boston, where there was a 313% gap between the lowest- and highest-priced hip replacement surgeries.
Overall, Montgomery, Alabama had the lowest average costs for knee and hip replacement surgeries (about $16,000 each), and New York City had the highest (about $60,000 each).
With ever-growing deductibles and other “cost-shifting” that increases out-of-pocket expenses for patients, it behooves individuals to talk to their doctor and their insurer, and to understand hospital charges as well as possible before agreeing to an elective procedure, orthopaedic or otherwise.