Eschew the “Quick Fix” Approach to Early Knee OA
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in Arthritis Care & Research, the following commentary comes from Jeffrey B. Stambough, MD.
As orthopaedic surgeons, we share a collective objective to help patients improve function while minimizing pain. When patients come to our office for a new clinical visit for knee osteoarthritis (OA), we spend time getting to know them and gathering information about their activities, limitations, and functional goals. We balance this patient-reported information with discrete data points, such as weight, range-of-motion restrictions, and radiographic disease classification. Based on the symptom duration and other factors, most patients are not candidates for a knee replacement at this first visit. However, despite the publication of clinical practice guidelines for the nonoperative management of knee OA in 2008, with an update in 2013, significant variation exists in how orthopaedists treat these patients.
This guideline–practice disconnect is emphasized in findings from a recent study in Arthritis Care & Research that examined nonoperative knee OA management practices during clinic visits between 2007 and 2015. The authors found that the overall prescription of NSAID and opioid medications increased 2- and 3-fold, respectively, over that time, while recommendations for lifestyle interventions, self-directed activity, and physical therapy decreased by about 50%.
To me, the most troubling finding from this study is the sharp increase in narcotic prescriptions, because recent evidence demonstrates that narcotics do not effectively treat arthritis pain. Moreover, for patients who go on to arthroplasty, recent studies have found that preoperative opioid use portends worse postsurgical outcomes in terms of higher revision rates, worse function scores, and decreased knee motion.
The findings from this study also speak to a larger societal issue for doctors and patients alike: the desire for a “quick fix.” Despite the time pressure from increasing EHR documentation burdens, dwindling reimbursements, or lack of local resources, we owe it to our patients to counsel them on lifestyle modifications and self-management strategies to help them stay mobile, lose weight (if necessary), and take charge of their joint health. As orthopaedic surgeons, we must continue to strive to de-emphasize opioid pain medication when treating knee OA patients and support them in a holistic manner to ensure their overall health and the function and longevity of their native knee joint.
Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.
Arthroscopy Beats PT for FAI at 8 Months
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent BMJ study, the following commentary comes from Matthew R. Schmitz, MD, FAOA.
Femoroacetabular impingement (FAI) syndrome continues to be a hot topic in the orthopaedic community. The first two decades of this century have seen huge increases in the number of hip arthroscopies performed in the US and UK,1,2 most of those to treat FAI. In the February 7, 2019 issue of BMJ, Palmer et al., reporting on behalf of the Femoroacetabular Impingement Trial (FAIT), published preliminary findings from a multicenter randomized controlled trial comparing arthroscopic hip surgery to activity modification and physiotherapy for symptomatic FAI.3
The trial randomized 222 patients with a clinical diagnosis of FAI into each cohort (110 in the physiotherapy group and 112 in the arthroscopy group). Follow-up assessments were performed by clinicians blinded to the treatment arm, and attempts were made to standardize both interventions. The participants will eventually be followed for 3 years, but this early report evaluated outcomes 8 months after randomization, with follow-up data available for >80% of patients in both groups.
Baseline characteristics with regard to demographics, radiographic findings, and clinical measurements were similar between the two groups. After adjusting for multiple potential confounders, the authors found that the mean Hip Outcomes Score Activities of Daily Living (HOS ADL) was 10 points higher in the arthroscopy group than in the physiotherapy group, exceeding the prespecified minimum clinically important difference (MCID) of 9 points. The MCID was reached in 51% of surgical patients compared to 32% in the therapy cohort. In addition, the patient acceptable symptomatic state (PASS)—defined as a HOS ADL ≥87 points—was achieved in 48% of surgical patients and only 19% of therapy patients. Relative to the physiotherapy group, the arthroscopic group also had better hip flexion and superior results in a variety of commonly used hip patient-reported outcomes scores.
The 8-month data from this study show that there is a real improvement in patient function and reported outcomes from arthroscopic management for FAI. It will be important, however, to follow these patients for the entire 3 years of the FAIT study to show whether these improvements persist. It should also be emphasized that only half of the patients treated with surgical management achieved MCID at the 8-month point. That finding supports what I tell patients in my young-adult hip-preservation clinics, which seems relevant as baseball season starts: There are rarely any home runs in arthroscopic hip surgery. There are mainly singles and doubles that we hope to stretch into doubles and triples. Still, it appears that even those base hits with arthroscopic surgery are better than the physiotherapy alternative—at least in the early innings of the game.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
References
- Maradit Kremers H, Schilz SR, Van Houten HK et al. Trends in Utilization and Outcomes of Hip Arthrocopy in the United States Between 2005 and 2013. J Arthroplasty 2017; 32:750-5.
- Palmer AJ, Malak TT, Broomfield J, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2018. BMJ Open Sport Exerc Med 2016;2:e000082
- Palmer AJ, Gupta VA, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicenter randomized controlled trial. BMJ 2019; 364:l185
August 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of August 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.”
The authors’ findings confirmed their hypothesis that robust risk adjustment is essential for objective comparison of patient-reported outcomes and for accurately reflecting quality of care among patients treated for low back pain.
Immobilization after Fixation of Distal Radial Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in JBJS.
Postoperative immobilization after internal fixation of fractures is common practice. However, immobilization after locked volar plate fixation of distal radial fractures may actually thwart our patients’ rehabilitation—at least in the short term. So suggest the findings from Watson et al. in the July 5, 2018 issue of JBJS.
The authors randomized 133 patients who underwent locked volar plate fixation of distal radial fractures to 1, 3, or 6 weeks of postoperative immobilization. All patients were placed into volar splints postoperatively. After 1 week, splints were removed entirely or converted to short-arm circumferential casts based on the patient’s allocation. All patients started physical therapy within 3 days of definitive splint or cast removal.
Outcomes were evaluated at 6, 12, and 26 weeks and included patient-reported measures (PRWE, VAS pain scores, and DASH), active wrist range of motion, and postoperative complications. Six weeks following surgery, the results favored 1 or 3 weeks of immobilization over 6 weeks of casting in terms of improved patient-reported outcomes and objective wrist range of motion. However, those between-group differences disappeared at 12 and 26 weeks of follow-up. No significant differences were found in complication rates between the 3 groups.
For me, the primary message of this article is that early mobilization after distal radial fracture fixation offers improved short-term outcomes with little or no risk of adverse effects. For most patients, a major goal of fracture treatment is to restore normal function as quickly as possible. With early mobilization, patients reported less pain and less disability, and they demonstrated greater range of motion at 6 weeks.
However, the quick restoration of function must be done safely and without complications. In this cohort, 6 patients lost fracture reduction—5 in the 1-week immobilization group and 1 in the 6-week group. While that difference was not statistically significant, the study was not sufficiently powered to detect that difference. A quick power analysis, assuming an anticipated 11% loss-of-reduction rate as seen in the 1-week group and a 2% rate as seen in the 6-week group, estimates that 234 patients would be needed to confidently avoid a type II error when analyzing loss of reduction.
Translating findings like these into practice constitutes the art of medicine. It is probably safe, and perhaps even beneficial, to allow early mobilization of distal radial fractures treated with volar locking plates. However, there is probably a subset of patients who are at risk for losing reduction, and therefore it may be prudent to have a low threshold for keeping certain patients casted for a longer duration. The orthopaedist who extends cast immobilization beyond 3 weeks can take comfort in the findings that reported outcomes and range of motion in the 6-week-immobilization group quickly caught up with the results of the early-mobilization cohorts by 12 weeks after surgery.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Orthopaedic Surgeons Hate Fixation Failures
Few things are more disheartening to an orthopaedic surgeon than taking a patient back into the operating suite to treat a failure of fixation. In part, that’s because we realize that the chances of obtaining stable fixation, especially in elderly patients with poor bone density, are diminished with the second attempt. We are additionally cognizant of the risks (again, most significant in the elderly) to cardiopulmonary function with a second procedure shortly after the initial one.
These concerns have led us historically to instruct patients to limit weight bearing for 4 to 6 weeks after hip-fracture surgery. On the other hand, we have seen evidence in cohort studies to suggest that instructing elderly patients with proximal femur fractures to bear weight “as tolerated” after surgery is safe and does not increase the risk of fixation failure.
In the June 6, 2018 issue of The Journal, Kammerlander et al. demonstrate that 16 cognitively unimpaired elderly patients with a proximal femur fracture were unable to limit postoperative weight bearing to ≤20 kg on their surgically treated limb—despite 5 training sessions with a physiotherapist focused on how to do so. In fact, during gait analysis, 69% of these elderly patients exceeded the specified load by more than twofold, as measured with insole force sensors. This inability to restrict weight bearing is probably related to balance and lower-extremity strength issues in older patients, but it may be challenging for people of any age to estimate and regulate how much weight they are placing on an injured lower limb.
With this and other recent evidence, we should instruct most elderly patients with these injuries to bear weight as comfort allows and prescribe correspondingly active physical therapy. As surgeons, we should focus our efforts on the quality and precision of fracture reduction and placement of surgical implants. This will lead to higher patient, family, and physical-therapist satisfaction and pave the way for a more active postoperative rehabilitation period and better longer-term outcomes.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Keeping a Clinical Eye on Downstream Costs
Medical economics has progressed to the point where musculoskeletal physicians and surgeons cannot ignore the financial implications of their decisions. Unfortunately, in most practice locations it is difficult, if not impossible, to ascertain the downstream costs to patients and insurers of our postsurgical orders for imaging, laboratory testing, and physical therapy (PT). In the April 18, 2018 issue of The Journal, Egol et al. present results from a well-designed and adequately powered randomized trial of outcomes after patients with minimally or nondisplaced radial head or neck fractures were referred either to outpatient PT or to a home exercise program focused on elbow motion.
At all follow-up time points (from 6 weeks to an average of 16.6 months), the authors found that patients receiving formal PT had DASH scores and time to clinical healing that were no better than the outcomes of those following the home exercise program. In fact, the study showed that after 6 weeks, patients following the home exercise program had a quicker improvement in DASH scores than those in the PT group.
The minor limitations with this study design (such as the potential for clinicians measuring elbow motion becoming aware of the treatment arm to which the patient was assigned) should not prevent us from implementing these findings immediately into practice. Each patient going to physical therapy in this scenario would have cost the healthcare system an estimated $800 to $2,400.
I wonder how many other pre- and postsurgical decisions that we routinely make would change if we had similar investigations into the value of ordering postoperative hemoglobin levels, surgical treatment of minimally displaced distal fibular fractures, routine postoperative radiographs for uncomplicated hand and wrist fractures, and PT after routine carpal tunnel release. These are just some of the reflexive decisions we make on a daily basis that probably have little to no value when it comes to patient outcomes. Whenever possible, we need to think about the downstream costs of such decisions and support the appropriate scientific evaluation of these commonly accepted, but possibly misguided, practices.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
February 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of February 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.”
The authors of this economic and decision analysis tackle a controversial topic: whether giving patients with neck and back pain direct access to physical therapy, without a medical referral, leads to lower costs of care. They also compare clinical outcomes in the medical-referral and direct-access groups.
Patient Satisfaction After ACL Reconstruction—Dec. 13 Webinar
We still have many unanswered questions about patient satisfaction after anterior cruciate ligament (ACL) reconstruction.
- Do specific patient populations benefit from more or fewer physical therapy (PT) visits?
- Does the cost of PT affect patient satisfaction?
- Should patients be classified by factors beyond their medical diagnoses to achieve the best outcomes while minimizing costs?
- What are the rates and predictors of return to play after ACL reconstruction? Does graft choice play a role?
- What is the relationship between return to play and patient satisfaction?
On Wednesday, December 13, 2017 at 8:00 PM EST, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary* LIVE webinar that addresses these important and clinically applicable questions.
JOSPT co-author Caitlin J. Miller, PT, DPT, will share the results of a retrospective cohort study examining the relationship between patient demographics, number of physical therapy visits, and the cost of postoperative interventions with revision rates and patient-reported outcomes following primary ACL reconstruction.
JBJS co-author Benedict U. Nawachukwu, MD, MBA, will discuss findings from a study of return to play and patient satisfaction among athletes following ACL reconstruction. This study also explores the efficacy of patellar tendon autografts and the preinjury impact of certain sports.
Moderated by Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA, a leading authority on the spine and the knee, the webinar will include additional insights from expert commentators Mark V. Paterno, PT, PhD, MBA, SCS, ATC, and Elizabeth Matzkin, MD. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.
Seats are limited so REGISTER NOW.
*All registrants will have free access to the webinar for 24 hours following the live broadcast.
Anatomic and Reverse Shoulder Replacement: Comparing Improvements Over Time
Although the indications for anatomic and reverse total shoulder arthroplasty (TSA) are different, better understanding of the rate of improvement with each type of surgery could help establish more realistic patient expectations for recovery—and help surgeons and physical therapists design different strategies for postoperative care. With those goals in mind, Simovitch et al. use prospectively collected data to compare, at a minimum 2-year follow-up, clinical and range-of-motion (ROM) outcomes among 505 anatomic TSA patients and 678 reverse TSA patients. The findings appear in in the November 1, 2017 issue of JBJS.
The authors tracked five clinical outcome scores (SST, UCLA Shoulder, ASES, Constant, and SPADI), along with 4 relevant ROM measures. In both groups, >95% of patients reported clinical improvement in all 5 clinical metrics by 6 months, and full improvement was noted by 24 months. Not surprisingly, the mean age of patients who underwent reverse TSA was >5 years older and their shoulder-function scores and ROM were generally worse than those of the anatomic TSA patients.
At the time of the latest follow-up, patients who underwent anatomic TSA fared significantly better than patients who underwent reverse TSA in 3 of the 5 clinical outcome metrics and in all 4 ROM measurements. On the other hand, those who had reverse TSAs had significantly larger improvements in the Constant score (which emphasizes strength more than the other 4 clinical metrics) and active forward flexion.
ROM-wise, at approximately 6 years after surgery, the authors noted a progressive decrease in the magnitude of improvement for abduction and forward flexion in both groups. According to Simovitch et al., the observed discrepancies between clinical and ROM outcomes at longer-term follow-up suggest that “subjective (e.g., patient-reported) assessments of outcome and function likely continue to be stable or improve despite range-of-motion worsening and, as such, may imply that patient expectations change with follow-up time.”
After THA, Self-Directed Home Exercise Yielded Same Benefits as Formal PT
An estimated 40% of total costs from a total hip arthroplasty (THA) episode are accrued from post-discharge services. With that in mind, Austin et al. embarked on a randomized controlled trial comparing outcomes among two groups of primary THA patients: those who followed a 10-week self-directed home exercise regimen (n=54) and those who received a combination of in-home and outpatient physical therapy (PT) for 10 weeks (n=54). The results were published in the April 19, 2017 edition of The Journal of Bone & Joint Surgery.
At 1 month and 6 to 12 months after surgery, patients in both groups showed significant preoperative-to-postoperative improvements in function as measured by all administered instruments (Harris Hip Score, WOMAC Index, and SF-36 Physical Health Survey). However, there was no difference in any of the measured functional outcomes between the two groups.
In addition, a total of 30 patients (28%) crossed over between groups: 20 (37%) from the formal physical therapy group and 10 (19%) from the home exercise group. The 10 patients who crossed over from home exercise to formal PT were not meeting progress goals; they tended to be older and had worse preoperative function than those in that cohort who did not cross over.
So, while this study provides evidence that unsupervised home exercise can be as effective as a structured rehabilitation program for most patients, the authors say the following patient characteristics might be indications for a referral to formal PT:
- Older age
- Poorer preoperative function
- Severe preoperative gait imbalance
- Postoperative neurological complications
- Expectations for quick return to high-level activity
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