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 January 20, 2016 Specialty Update on adult reconstructive knee surgery:
Nonsurgical Management and Osteotomy
- A Cochrane database review found that land-based therapeutic exercise programs were modestly beneficial to patients with knee arthritis. Individualized programs were more effective than exercise classes or home-exercise programs.1
- A study comparing intravenous administration of tanezumab versus naproxen and placebo in patients with hip and knee osteoarthritis found that tanezumab effectively relieved pain and improved function at week 16.2
- A comparison of platelet-rich plasma (PRP) injections and hyaluronic acid (HA) injections found both treatments to be equally effective in improving knee function and reducing symptoms as measured by the IKDC subjective score.3
- A study comparing opening-wedge and closing-wedge high tibial osteotomy found that among patients who did not go on to conversion to TKA, there were no between-group differences in clinical or radiographic outcomes at six years of follow-up.
Implants, Instrumentation, and Technique
- A comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting TKA found no differences in pain, function, and radiographic outcomes at a mean of 5.9 years.
- A randomized study of 140 patients that compared the use of patient-specific instrumentation (PSI) and conventional instrumentation found no differences in clinical, operative, and radiographic results.4
- In a randomized trial of 200 patients, the use of electromagnetic computer navigation resulted in insignificantly fewer outliers from the target alignment, compared with the use of conventional instrumentation. There were no between-group differences in clinical outcomes.5
- In a prospective randomized trial, the use of computer-assisted navigation during TKA resulted in lower systemic embolic loads, compared with TKA performed using conventional intramedullary instrumentation.
- A randomized controlled trial comparing kinematically and mechanically aligned TKA found that kinematic alignment with patient-specific guides provided better pain relief and restored better function and range of motion than mechanical alignment using conventional instruments.6
- A randomized study of selective patellar resurfacing in 327 knees followed for a mean of 7.8 years found higher satisfaction among patients with a resurfaced patella.7
Pain and Blood Management
- A randomized controlled trial comparing femoral and adductor canal blocks found that adductor canal blocks decreased time to discharge readiness without an increase in narcotic consumption.8
- A trial comparing periarticular injections (PAIs) of liposomal bupivacaine with conventional bupivacaine PAI found no between-group differences in VAS pain scores 72 hours postoperatively or in patient narcotic consumption.9
- A double-blinded randomized trial comparing topical versus intravenous administration of tranexamic acid found no significant differences in estimated blood loss or complications.
Rehabilitation and Complications
- A randomized trial of 205 post-TKA patients found no differences in WOMAC scores for pain, function, and stiffness in groups that received telerehabilitation or face-to-face home therapy.
- A randomized trial found that Kinesio Taping helped reduce postoperative pain and swelling and improved knee extension during early postoperative rehabilitation.10
- A trial comparing oral edoxaban and subcutaneous enoxaparin for post-TKA thromboprophylaxis found that edoxaban was the more effective agent. The incidence of bleeding events was similar in both groups.11
- Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL.Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev.2015;1:CD004376. Epub 2015 Jan 9.
- Ekman EF, Gimbel JS, Bello AE, Smith MD, Keller DS, Annis KM, Brown MT, WestCR, Verburg KM. Efficacy and safety of intravenous tanezumab for the symptomatic treatment of osteoarthritis: 2 randomized controlled trials versus naproxen. J Rheumatol. 2014 Nov;41(11):2249-59. Epub 2014 Oct 1.
- Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, MarcacciM, Kon E. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015Jul;43(7):1575-82. Epub 2015 May 7.
- Abane L, Anract P, Boisgard S, Descamps S, Courpied JP, Hamadouche M. A comparison of patient-specific and conventional instrumentation for total knee arthroplasty: a multicentre randomised controlled trial. Bone Joint J. 2015 Jan;97-B(1):56-63.
- Blyth MJ, Smith JR, Anthony IC, Strict NE, Rowe PJ, Jones BG. Electromagnetic navigation in total knee arthroplasty-a single center, randomized, single-blind study comparing the results with conventional techniques. J Arthroplasty. 2015Feb;30(2):199-205. Epub 2014 Sep 16.
- Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J. 2014 Jul;96-B(7):907-13.
- Roberts DW, Hayes TD, Tate CT, Lesko JP. Selective patellar resurfacing in total knee arthroplasty: a prospective, randomized, double-blind study. J Arthroplasty.2015 Feb;30(2):216-22. Epub 2014 Sep 28.
- Machi AT, Sztain JF, Kormylo NJ, Madison SJ, Abramson WB, Monahan AM,Khatibi B, Ball ST, Gonzales FB, Sessler DI, Mascha EJ, You J, Nakanote KA, IlfeldBM. Discharge readiness after tricompartment knee arthroplasty: adductor canal versus femoral continuous nerve blocks-a dual-center, randomized trial.Anesthesiology. 2015 Aug;123(2):444-56
- Schroer WC, Diesfeld PG, LeMarr AR, Morton DJ, Reedy ME. Does extended-release liposomal bupivacaine better control pain than bupivacaine after total knee arthroplasty (TKA)? A prospective, randomized clinical trial. J Arthroplasty. 2015Sep;30(9)(Suppl):64-7. Epub 2015 Jun 3.
- Donec V, Kriščiūnas A.The effectiveness of Kinesio Taping after total knee replacement in early postoperative rehabilitation period. A randomized controlled trial. Eur J Phys Rehabil Med. 2014 Aug;50(4):363-71. Epub 2014 May 13.
- Fuji T, Wang CJ, Fujita S, Kawai Y, Nakamura M, Kimura T, Ibusuki K, Ushida H, Abe K, Tachibana S.Safety and efficacy of edoxaban, an oral factor Xa inhibitor, versus enoxaparin for thromboprophylaxis after total knee arthroplasty: the STARS E-3 trial. Thromb Res. 2014 Dec;134(6):1198-204. Epub 2014 Sep 21.
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 September 16, 2015 Specialty Update on hip replacement:
Transfusion and Blood Management
–Studies continue to demonstrate that tranexamic acid decreases the need for transfusion when used either intravenously or topically.
–The routine use of a drain following total hip replacement, even when used for reinfusion of shed blood, provides little to no benefit and does not decrease the risk of transfusion.1
Preoperative Patient Teaching
–A Cochrane review concluded that preoperative teaching resulted in only modest improvements in quality of life, pain scores, anxiety, and function. Patients with depression, anxiety, and unrealistic expectations might receive the most benefit from these interventions.2
–A meta-analysis demonstrated short-term superiority of the direct anterior approach over the posterior approach, but the authors concluded there was insufficient evidence of clear long-term superiority of either approach.3
–A study that reviewed the results of two academic surgeons who exclusively used either the direct anterior approach or a miniposterior approach found no systematic advantage to either approach in terms of surgical time, pain, or function. This suggests that factors other than surgical approach may be more important in influencing early recovery after hip replacement.4
–A randomized trial comparing survivorship in four cemented femoral stem designs concluded that, in the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups, a polished surface conferred improved survivorship.5
–A multivariate registry-based meta-analysis found that, in patients who were 75 years or older, uncemented fixation had a significantly higher risk of revision than hybrid fixation.
— A multivariate registry-based meta-analysis concluded that use of ceramic implants with a smaller head size in cementless hip arthroplasty was associated with a higher risk of revision, compared with metal-on-highly cross-linked polyethylene and >28-mm ceramic-on-ceramic implants.
–A registry-based cohort study comparing revision rates in metal-on-conventional polyethylene bearings with metal-on-highly cross-linked polyethylene bearings found a rate over seven years of 5.4% for the conventional polyethylene bearing versus 2.8% for the highly cross-linked bearing.6
–A randomized study comparing metal-ion levels five years after metal-on-metal and metal-on-polyethylene hip replacements found significantly lower cobalt and chromium levels in the metal-on-polyethylene group.
–A multivariate meta-analysis comparing the risk of revision for metal-on-conventional and metal-on-highly cross-linked polyethylene implants in patients 45 to 64 year old did not find a difference between the two groups.
–A meta-analysis comparing ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene found no differences in medium-term survivorship.7
- Thomassen BJ, den Hollander PH, Kaptijn HH, Nelissen RG, Pilot P. Autologous wound drains have no effect on allogeneic blood transfusions in primary total hip and knee replacement: a three-arm randomised trial. Bone Joint J. 2014 Jun;96-B(6):765-71.
- McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev.2014;5:CD003526. Epub 2014 May 13.
- Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015Mar;30(3):419-34. Epub 2014 Oct 22.
- Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res. 2015 Feb;473(2):623-31.
- Hutt J, Hazlerigg A, Aneel A, Epie G, Dabis H, Twyman R, Cobb A. The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs. Int Orthop. 2014 Jun;38(6):1131-7. Epub 2014 Jan 29.
- Paxton EW, Inacio MC, Namba RS, Love R, Kurtz SM. Metal-on-conventional polyethylene total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry. Clin Orthop Relat Res. 2015 Mar;473(3):1011-21.
- Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, Trousdale RT.There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.
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 June 17, 2015 Specialty Update on spine surgery:
- A database study to determine the prevalence of venous thromboembolic events after spinal fusion found that risk factors for such events included hypercoagulability, certain medical comorbidities, older age, and male sex.
- An RCT comparing allograft alone versus allograft plus bone marrow concentrate to accomplish spine fusion in adults with spondylolisthesis found very poor union rates in both groups, although allograft with bone marrow concentrate delivered slightly better results.
- A meta-analysis of five studies (253 patients) found no pain or functional differences when unilateral percutaneous kyphoplasty was compared with bilateral (same-vertebra) kyphoplasty for osteoporotic compression fractures. The unilateral approach was associated with shorter operative times, however.
- An RCT comparing the analgesic efficacy and clinical utility of gabapentin, pregabalin, and placebo in patients undergoing spinal surgery found that pregabalin outperformed the other two interventions immediately after surgery postoperative and up to three months postoperatively.
- In an RCT comparing open-door to French-door laminoplasty for cervical compressive myelopathy, both techniques were found to be equivalent in terms of neurological recovery and perioperative complications, but patients receiving the open-door technique had more kyphosis and less cervical range of motion postoperatively.
- An update to a 2002 Cochrane review found no significant outcome differences between supervised and home-exercise rehabilitation programs after lumbar disc surgery.
- A systematic review/meta-analysis showed that radiofrequency denervation of facet joints is more effective than placebo in achieving functional improvement and pain control in patients with chronic low back pain.
- A Level II diagnostic study concluded that with a magnification of 150% and a good pair of flexion and extension radiographs following anterior cervical arthrodesis, pseudarthrosis was noted with >1 mm of motion between fused interspinous processes with 96.1% specificity and a positive predictive value of 96.9%.
- A Level I therapeutic study comparing the efficacy of intravenous tranexamic acid, epsilon-aminocaproic acid, and placebo to reduce bleeding in 125 adolescent patients undergoing posterior fusion for idiopathic scoliosis found less intraoperative and postoperative blood loss and higher hematocrit levels with the antifibrinolytics than with placebo. However, transfusion requirements were no different between the groups.
- A randomized comparison of navigated versus freehand techniques for pedicle screw insertion during lumbar procedures found that surgeon radiation exposure with freehand technique is up to 10 times greater than with use of navigation.
With 840 scientific presentations, 560 posters, and 200 instructional course lectures, even OrthoBuzz couldn’t comprehensively summarize the 2014 AAOS Annual Meeting in New Orleans. But here’s a small random sampling of findings reported at the meeting that you might find interesting. Please remember that these data have not appeared in peer-reviewed journals and should be considered preliminary.
TENS for Low Back Pain Could Save Medicare Nearly a Half-Billion Dollars
If all of its estimated 1.5 million beneficiaries with chronic low back pain were treated with TENS—transcutaneous electrical nerve stimulation—Medicare could save about $417 million in annual treatment costs, said Michael Minshall, MPH (paper #474). The figures are based partly on published research showing that TENS patients use significantly fewer health care resources (hospital and office visits, imaging, physical therapy, and surgery) than those receiving other treatments.
Allografts Fail Three Times More Frequently than Autografts in Primary ACL Reconstruction
A prospective randomized trial of 99 ACL reconstruction patients in their twenties revealed a 10-year 26.5% failure rate when tibialis posterior tendon allografts were used, compared with an 8.5% failure rate for hamstring autografts. Presenter Craig Bottoni, MD (paper # 462) said both groups received the same fixation technique and the same postoperative rehab program by physical therapists who were blinded to the treatment allocation.
Tranexamic Acid Cuts Transfusion Rates during TJA without Boosting VTEs
Scott Wingerter, MD (paper #1) presented data from Washington University School of Medicine (WUSM) showing that transfusion rates declined substantially during primary and revision hip and knee replacement procedures after tranexamic acid began being used routinely at WUSM. The incidence of venous thromboembolism was also lower in the group that received tranexamic acid, although that difference was not statistically significant.
Repeat Skin Antisepsis May Reduce Surgical Site Infections
A randomized, prospective study of nearly 600 patients undergoing total joint replacement found that those who received additional skin antisepsis with an iodine povacrylex/alcohol combination after surgical draping but before incise draping were far less likely to experience a superficial surgical site infection than those who received standard skin preparation with chlorhexidine, alcohol, and betadine. Presenter Tiffany Morrison, MS (paper # 49) also noted a non-significant difference in rates of skin blistering between the two groups.