Tag Archive | total hip arthroplasty

JBJS 100: Metal-on-Metal Hips and Shoulder Function

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip Joints
H-G Willert, G H Buchhorn, A Fayyazi, R Flury, M Windler, G Köster, C H Lohmann: JBJS, 2005 January; 87 (1): 28
At the turn of the 21st century, many efforts were underway to discover why some patients who had received second-generation metal-on-metal hip replacements were having postoperative problems. This clinical and histomorphological study, illustrated with detailed tissue sections, showed that a lymphocyte-dominated immunological response could be involved.

Observations on the Function of the Shoulder Joint
V T Inman, J B deC M Saunders, L C Abbott: JBJS, 1944 January; 26 (1): 1
Back in the days when 30-page JBJS articles were not uncommon, these authors set out to examine the whole shoulder mechanism, with detailed anatomical drawings, radiographic analysis, and action potentials derived from living shoulder muscles. This comprehensive, “eclectic approach” was published at a time when polio was endemic, but it is still relevant today.

During First Post-Op Month, Periprosthetic Fractures Are as Lethal as Native Hip Fractures

periprosthetic hip fxIn 1922, Kellogg Speed, MD said in his American College of Surgeons address, “We enter the world under the brim of the pelvis and exit through the neck of the femur.” Since then, it has been repeatedly shown that femoral-neck and intertrochanteric hip fractures are associated with a high mortality rate during the first year following fracture. Now, in the era of widespread hip arthroplasty—and with the consequently increasing rates of periprosthetic fractures near the hip joint—it is relevant to ask whether periprosthetic fractures are associated with an increased risk of mortality similar to that seen after native hip fractures. In the April 4, 2018 issue of The Journal, Boylan et al. use the New York Statewide Planning and Research Cooperative System database to address that question.

The authors reviewed 8 years of native and periprosthetic hip fracture data to determine whether the 1-month, 6-month, and 12-month mortality risk between the two patient cohorts was similar. They found that the 1-month mortality risk in the two groups was similar (3.2% for periprosthetic fractures and 4.6% for native fractures). However, there were significant between-group differences in mortality risk at the 6-month (3.8% for periprosthetic vs 6.5% for native) and 12-month (9.7% vs 15.9%) time points.

This makes clinical sense because, in general, patients experiencing a native hip fracture have lower activity levels and general fitness and higher levels of comorbidity than patients who have received a total hip arthroplasty. Extensive research has resulted in protocols for lowering the risk of mortality associated with native hip fractures, such as surgery within 24 to 48 hours, optimizing medical management through geriatric consultation, and safer and more effective rehabilitation strategies. We need similar research to develop effective perioperative protocols for patients experiencing a periprosthetic fracture, as this study showed that 1 out of 10 of these patients does not survive the first year after sustaining such an injury. I also agree with the authors’ call for more research to identify patients with periprosthetic fractures who are “at risk of worse outcomes at the time of initial presentation to the hospital.”

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Will a Hip Replacement Help You Live Longer?

THA for OBuzzThis tip comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

It is well-established that total hip arthroplasty (THA) improves quality of life, but how about longevity itself? Cnudde et al.1 attempted to identify associations between THA and lower mortality rates, acknowledging that such rates may also be influenced by diagnostic, patient-related, socioeconomic, and surgical factors.

Using data from the Swedish Hip Arthroplasty Register, the authors identified 131,808 patients who underwent THA between January 1, 1999 and December 31, 2012. Among those patients, 21,755 died by the end of follow-up. Relative survival among the THA patients was compared with age- and sex-matched survival data from the entire Swedish population.

Patients undergoing elective THA had a slightly improved survival rate compared with the general population for approximately 10 years after surgery, but by 12 years, there was no survival-rate difference between patients undergoing THA and the general population (r = 1.01; 95% CI, 0.99-1.02; p = 0.13).

After controlling for other relevant factors and using primary osteoarthritis as the reference diagnosis, the authors found that patients undergoing THA for osteonecrosis of the femoral head, inflammatory arthritis, and secondary osteoarthritis had poorer relative survival.

In addition, married patients and those with higher levels of education fared better. The authors could not pinpoint the reasons for the increase in relative survival among THA patients, but these findings suggest that the explanation is most likely multifactorial.

Reference

  1. Do Patients Live Longer After THA and Is the Relative Survival Diagnosis-specific?Cnudde P, Rolfson O, Timperley AJ, Garland A, Kärrholm J, Garellick G, Nemes S. Clin Orthop Relat Res. 2018 Feb 28. doi: 10.1007/s11999.0000000000000097. [Epub ahead of print]

JBJS 100: Infection Prevention and Hip Replacement Rates

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Prevention of Infection in Treatment of 1,025 Open Fractures of Long Bones
R B Gustilo and J T Anderson: JBJS, 1976 June; 58 (4): 453
While “best practices” for managing open long-bone fractures have changed since this landmark study was published, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains widely accepted for research and training purposes, and it provides commonly used basic language for communicating about open fractures.

Rates and Outcomes of Primary and Revision Total Hip Replacement in the US Medicare Population
N N Mahomed, J A Barrett, J N Katz, C B Phillips, E Losina, R A Lew, E Guadagnoli, W H Harris, R Poss, J A Baron: JBJS, 2003 January; 85 (1): 27
Analyzing Medicare claims data between July 1, 1995 and June 30, 1996, the authors of this prognostic study claimed it was “the first population-based study of the rates of revision total hip replacement and its short-term outcomes.” In the last 10 years alone, more than 5,000 studies on revision THA have been published in PubMed-indexed journals, including this 2012 JBJS study, which examined THA revision risk in the same Medicare cohort over 12 years.

JBJS 100: Controlling Bone Growth and Revision THA Stats

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Control of Bone Growth by Epiphyseal Stapling: A Preliminary Report
W P Blount and G R Clarke: JBJS, 1949 July; 31 (3): 464
This 14-page, amply illustrated article was the oldest paper selected by Kavanagh et al. in their 2013 JBJS bibliometric analysis of the 100 classic papers of pediatric orthopaedics. Blount and Clarke proved definitively that long-bone growth could be arrested by appropriately timed epiphyseal stapling and that growth would resume after staple removal. Their work spared many children with linear or angular leg deformities—often a result of polio—from the risk of more invasive operative methods.

Epidemiology of Revision Total Hip Arthroplasty in the US
K J Bozic, S M Kurtz, E Lau, K Ong, T P Vail, D J Berry: JBJS, 2009 January; 91 (1): 128
Fast forwarding 60 years from the Blount and Clarke study, we arrive at this epidemiological analysis of >51,000 revision hip replacements. The findings from this 2009 Level II prognostic study provided information that has guided THA research, implant design, and clinical decision-making throughout the past decade.

With New Technologies, Slow Adoption is Best

MoM for OBuzzThe enemy of the good is the better. It’s an axiom we hear during our surgical training, and it was my first thought when reading the article by Hunt et al. in the February 7, 2018 edition of JBJS.  The authors examine failure rates associated with the rapid adoption and widespread use of metal-on-metal (MoM) total hip arthroplasties (THAs) and hip resurfacings.

Carefully analyzing data from the National Joint Registry for England, Wales and Northern Ireland from 2003 to 2014, Hunt et al. ascertained that MoM hip resurfacings and MoM total hip arthroplasties resulted in 10-year revision rates that were almost 3 and 5 times higher, respectively, than the expected revision rates for standard hip procedures. This meant that within 10 years, there were almost 8 excess revisions for every 100 MoM hip resurfacings and almost 16 excess revisions for every 100 MoM total hip arthroplasties. Just as troubling was the finding that 20% of those excess revisions needed at least one additional revision within 7 years.

As orthopaedic surgeons, we strive to make things better for patients, which may tempt us to try a “new and improved” technology for a nominal (or presumed) improvement in outcome, when the one we are currently using works just fine. It is our responsibility as surgeons not to be blind to the unintended consequences new technologies may have on our patients.

I agree with the blunt directive Hunt et al. issue in the final sentence of their abstract: “This practice of adopting new technologies without adequate supporting data must not be repeated.”

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS 100: Carpal Tunnel and THA

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Carpal Tunnel Syndrome: Seventeen Years’ Experience in Diagnosis and Treatment of 654 Hands
George S. Phalen: JBJS, 1966 March; 48 (2): 211
Everything Phalen presented about carpal tunnel syndrome in 1966 holds true more than 50 years later. This includes his descriptions of the anatomical, epidemiologic, histologic, and clinical features of carpal tunnel syndrome and his emphasis on careful history-taking and physical examination.

Periprosthetic Bone Loss in Total Hip Arthroplasty: Polyethylene Wear Debris and the Concept of the Effective Joint Space
T P Schmalzried, M Jasty, W H Harris: JBJS, 1992 Jan; 74 (6): 849
The insights offered by these authors radically altered our thoughts about osteolysis. Using this concept of effective joint space, subsequent investigators and innovators identified methods and designs of hip replacements to retard osteolysis by limiting the generation and spread of particulate debris.

Webinar on Feb. 12—Surgical Approaches to Hip Replacement

Feb Webinar speakers for OBuzzEvery surgical approach to total hip arthroplasty (THA)—posterior, anterior, or lateral and conventional or minimally invasive—has adherents and critics. Despite scores of published studies comparing these different approaches, no single best practice has yet emerged.

On Monday, February 12, 2018 at 6:30 PM EST, JBJS will present a complimentary* webinar that addresses this ongoing debate with recent evidence about five different surgical approaches to THA. Moderated by James Waddell, MD, former President of the Canadian Orthopaedic Association, the webinar will springboard off two JBJS articles:

  • Knut Erik Mjaaland, MD will discuss a registry study that found no significant 5-year outcome differences among four different approaches: two minimally invasive (anterior and anterolateral), and two conventional (posterior and direct lateral).
  • R. Michael Meneghini, MD will explain why his group concluded that the direct anterior approach may confer a greater risk of early femoral component failure due to aseptic loosening, compared with the direct lateral or posterior approaches.

After the authors’ presentations, Anthony Unger, MD and Tad Mabry, MD will add clinical perspectives to the current state of this important research. During the last 15 minutes of the webinar, panelists will answer questions from the audience.

Space is limited, so Register Now.

* This webinar is complimentary for those who attend the event live and will continue to be available for 24 hours following its conclusion.

High Value Joint Replacements at Physician-Owned Hospitals

H image for OBuzzIn the November 15, 2017 issue of The Journal, Courtney et al. carefully evaluate CMS data to compare TKA and THA costs, complications, and patient satisfaction between physician-owned and non-physician-owned hospitals. The authors used risk-adjusted data when comparing complication scores between the two hospital types, in an attempt to address the oft-rendered claim that surgeons at physician-owned facilities “cherry pick” the healthiest patients and operate on the highest-risk patients in non-physician-owned facilities.

In general, the findings suggest that, for TKA and THA, physician-owned hospitals are associated with lower costs to Medicare, fewer complications and readmissions, and superior patient-satisfaction scores compared with non-physician-owned hospitals. These findings should come as no surprise to readers of The Journal. One fundamental principle of health care finance is that physicians control 70% to 80% of the total cost of care with their direct decisions. When physician incentives are aligned with those related to the facility, the result is better care at lower cost.

Nevertheless, many policymakers remain convinced that physician-owners are completely mercenary and base every decision on maximizing profit margins—even if that includes ordering unnecessary tests, performing unnecessary procedures, or using inferior implants. We need more transparency among physician-owners at local and national levels to address these usually-erroneous assumptions, which are frequently repeated by local non-physician-owned health systems. For example, we should be transparent with the percentage of the margin that ends up in the physician-owner’s pocket. Whatever the “right” percentage is, I believe it should not be the dominant factor in a physician’s total income..

The findings from Courtney et al. should spur further debate on this issue. I am confident that the best outcomes for individual patients and the public result when physicians (and their patients) stay in direct control of decision making regarding care, when surgeons are appropriately motivated to be cost- and outcome-effective, and when we all do our part to care for the under- and uninsured.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Certain Comorbidities Boost Risk of Acute Kidney Injury after THA

AKI Risk for OBuzzThe relationship between chronic kidney disease (CKD) and acute kidney injury (AKI) is circular: surgical patients with preexisting CKD are at increased risk of AKI, and even mild or transient AKI is associated with future development of CKD.

In the November 1, 2017 JBJS, Gharaibeh et al. report findings from a retrospective cohort study with a nested case-control analysis that assessed the rate and risk factors associated with AKI after total hip arthroplasty (THA).

From a total of 10,323 THAs analyzed, AKI developed postoperatively in only 114 cases (1.1%). A multivariate analysis of the entire cohort identified four preoperative comorbidities that increased the risk of AKI by 2- to 4-fold: CKD, heart failure, diabetes, and hypertension. In addition to those risk factors, an analysis of the case-control cohort found that increasing BMI and perioperative blood transfusions were also associated with a higher risk of AKI.

Using data from the entire cohort, the authors developed an AKI risk calculator focused on presurgical variables (see graph). Based on that model, which will require independent validation, a 65-year-old man with either CKD or heart failure would have a 2% risk of AKI; the risk would increase to 4% if that patient had CKD and hypertension and to 16.1% in the presence of CKD, hypertension, and heart failure.

The anticipated increase in demand for joint replacements could lead to US surgeons performing approximately 572,000 THAs during the year 2030. A certain (and possibly increasing) proportion of those future procedures will occur in patients who have hypertension, diabetes, heart failure, and/or chronic kidney disease. The findings from Gharaibeh et al., especially the yet-to-be-validated AKI risk score, could help hip surgeons better counsel patients and identify those who might benefit from heightened postsurgical monitoring of kidney function.