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Knee, Hip, and Shoulder News


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KNEE NEWS Vol.3 No.26

Early surgery is said to improve
outcomes, and reduce morbidity

MUMBAI, INDIA – Early hip-fracture surgery improves outcomes and reduces morbidity, bed sores, and infections, according to a study indicating that hospital-stay length can be improved by reducing surgery-waiting times after fractures.

The retrospective study published in October in the European Journal of Orthopaedic Surgery & Traumatology also indicates that it is beneficial that elderly patients receive surgical treatment as early as possible.

Its authors----including S. K. Rai and Rohit Varma, Indian Naval Hospital Ship Asvini, Mumbai, India---note that there is conflicting evidence in published data that early surgery improves mortality and function, and set out to assess whether any correlation exists between early surgical intervention and functional outcomes.

The researchers noted that hip fractures among the elderly are usually associated with high morbidity rates, and affect quality of life. They reviewed published data and noted that current guidelines in the literature indicate that early surgery should be performed within 24 hours of injury, as it is associated with better functional outcomes and lower rates of perioperative complications and mortality.

They analyzed records between January, 2010, and December, 2016; 550 patients between the ages of 65 and 95 were included.

Early-surgery results were promising:

  • 451 patients had no complications
  • 42 developed bed sores
  • 23 developed hospital-acquired infections
  • 13 developed wound infections
  • eight developed deep-vein thrombosis (DVT)
  • four developed implant failures
  • nine died of complications

CITATION: S. K. Rai, Rohit Varma, et. al. Does time of surgery and complication have any correlation in the management of hip fracture in elderly and can early surgery affect the outcome? European Journal of Orthopaedic Surgery & Traumatology. 07 October 2017.  https://link.springer.com/article/10.1007%2Fs00590-017-2047-0

Review recounts successful effort
in treatment of injured para-skier

DENVER – A recently-published clinical review of efforts assisting an injured para-skier indicates that excellent stabilization was achieved.
The review published in September in The American Journal of Orthopedics indicates that while the patient had setbacks related to pain and decreased range of motion (ROM), second surgery and continued physical therapy will probably help him return to pre-operative recreational-activity levels.

The researchers---including Chase S. Dean, University of Colorado, Denver---describe the diagnosis, treatment, rehabilitation, and complications of a para-skier, 27, who sustained a closed high-velocity knee dislocation after colliding with a tree at a speed of 45 mph and falling 40 feet to the ground.
Extensive surgery was performed to repair and reconstruct the knee, including:

  • open lateral-capsular repair
  • open anatomical-posterolateral corner (PLC) reconstruction with split Achilles-tendon allograft
  • open iliotibial-band (ITB) reconstruction with Achilles-tendon allograft
  • arthroscopic-anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft
  • double-bundle posterior-cruciate ligament reconstruction with Achilles-tendon allograft for the anterolateral bundle and tibialis anterior-tendon allograft for the posteromedial bundle

Follow-up surgery was performed to treat arthrofibrosis; post-operative stress radiographs and subjective outcomes demonstrated that stability was excellent overall.
Take-home points include:

  • reconstruction of a torn ITB is important in restoration of native anatomy and function
  • restoration of posterolateral instability primarily involves reconstructing the fibular collateral ligament (FCL), popliteus tendon (PLT), and popliteofibular ligament
  • for combined PLC injuries, concurrent reconstruction of the cruciate ligaments in one stage is highly recommended
  • post-surgery, a six-week non-weight-bearing, limited flexion rehab protocol utilizing a dynamic PCL brace is recommended to prevent posterior-tibial sag
  • arthrofibrosis and decreased ROM can be seen following a violent knee injury requiring extensive multi-ligament reconstruction surgeries

CITATION: Chase S. Dean, MD, Olivia Fernandes, MS, ATC, et. al. Paraskiing Crash and Knee Dislocation With Multiligament Reconstruction and Iliotibial Band Repair. Am J Orthop. 2017 September;46(5): E301-E307. http://www.mdedge.com/amjorthopedics/article/148381/knee/paraskiing-crash-and-knee-dislocation-multiligament

Significant improvements reported
in an assessment of RSA with LDTT

SEATTLE – A systematic review published recently in The American Journal of Orthopedics describing demographics and outcomes of patients who underwent reverse shoulder arthroplasty (RSA) with latissimus dorsi tendon transfer (LDTT) indicates significant improvements in various subjective values, active-forward elevation, external rotation, and abduction strength.

The clinical review published in September utilized compiled data and frequency-weighted (FW) means; its authors include Jia-Wei Kevin Ko, who is based in Seattle.

For RSA with LDTT and RSA alone, complication rates appear comparable, but the rate of neuropraxia may be higher for the combined procedure.

Although this review provides valuable information on RSA with LDTT, its lack of a control-comparison group and its relatively short follow-up period limited the researchers’ ability to draw meaningful conclusions about the efficacy of the combined procedure in treating rotator cuff tear arthropathy (CTA) in the absence of a functional teres minor.

Its take-home points include:

  • CTA with loss of teres minor has been associated with worse clinical outcomes
  • combined RSA and LDTT has been proposed and studied as a solution to this problem
  • LD tendon can be transferred to native teres-minor insertion or lateral-bicipital groove
  • published studies have shown significant improvements in various subjective values, active-forward elevation, external rotation, and abduction strength
  • overall complication rates appear similar to RSA alone; however, rates of neuropraxia may be higher

The researchers focused on three questions:

  • What are the demographics of patients treated with RSA-LDTT?
  • What outcomes are associated with this combined procedure?
  • What are the associated complications, and how often do they occur?

CITATION: Mihir Sheth, BS, Jia-Wei Kevin Ko, MD, et. al. Reverse Shoulder Arthroplasty and Latissimus Dorsi Tendon Transfer. Am J Orthop. 2017 September; 46(5): E287-E292. http://www.mdedge.com/amjorthopedics/article/147677/shoulder-elbow/reverse-shoulder-arthroplasty-and-latissimus-dorsi?channel=295

Lower pain observed in separate
double-layer double-row repairs

SEOUL, SOUTH KOREA – Both conventional en-masse repairs and separate double-layer double-row repairs are effective in improving clinical outcomes in treating delaminated rotator-cuff tears, according to a study indicating that lower pain scores are seen in patients undergoing separate double-layer double-row repairs.

The prospective study published in October in Arthroscopy was designed to determine the optimal surgical method for delaminated rotator-cuff tears.

Its authors---including Yang-Soo Kim, The Catholic University of Korea, Seoul, South Korea---assessed data from between August, 2007 and March, 2014, involving 82 patients who underwent arthroscopic rotator-cuff repairs of delaminated tears.

Patients were randomized into two groups: 48, making up the first group, underwent arthroscopic conventional en-masse repairs, while 34 underwent separate double-layer double-row repairs; articular layer was repaired in knotless manner.

The American Shoulder and Elbow Surgeons score, Constant score, Simple Shoulder Test score, and visual analog scale (VAS) score for pain and range of motion (ROM) were assessed pre-surgery; three, six, and 12 months post-surgery; and at final follow-ups.

Magnetic resonance imaging (MRI) was performed 12 months post-operatively to examine re-tear rates and patterns.

There was no significant difference between groups in pre-operative demographic data that included patient age, sex, symptom duration, tear size, and functional scores.

Mean follow-up period was 25.9 months; group two had significantly lower VAS pain scores post-operatively at three, six, and 12 months.

Functional scores and ROM showed no significant difference between groups at each time point; eight of 48 patients in group one and six of 34 in group two showed re-tears on MRI at 12-month follow-up, but the difference was not statistically significant.

CITATION: Yang-Soo Kim, MD, Ph.D., Aaron Beach, Ph.D., et. al. Which is Better Between Conventional En Masse Repair Versus Separate Double-Layer Double-Row Repair for the Treatment of Delaminated Rotator Cuff Tears: A Prospective Randomized Study. Arthroscopy. October 2017. Volume 33, Issue 10, Supplement, Page e106. http://www.arthroscopyjournal.org/article/S0749-8063(17)30919-2/fulltext?rss=yes


KNEE NEWS Vol.3 No.25


DAIR, two-stage revision seen
as similar in terms of success

OXFORD, ENGLAND – The debridement, antibiotics and implant retention (DAIR) procedure in hip periprosthetic joint infection (PJI) is associated with a similar complication rate and ability to eradicate infection as two-stage revision, according to a recent study.

The case-control study published in May in The Bone & Joint Journal emphasizes the need for exchange of modular components for improved chances of eradication of infection.

The researchers---including George Grammatopoulos, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, England---compared DAIR outcomes for infected primary total hip arthroplasty (THA) with outcomes following primary THA and two-stage revision of infected primary THAs.

They retrospectively reviewed all 82 DAIRs performed for confirmed infected primary hip arthroplasty at one facility between 1997 and 2013.

Outcome measures included complications, mortality, implant survivorship and functional outcome; outcome was compared with two control groups matched for gender and age.

Mean age at DAIR was 69 years, and mean follow-up was eight years.

Fifty-two DAIRs were for early PJI (less than six weeks); greater success in the eradication of infection with DAIR was identified with early PJI, comprising an interval less than a week between onset of symptoms and exchange of modular components with the DAIR procedure.

Eradication of infection, complications, and re-operation rates were similar in the DAIR and two-stage revision groups. For hips with successful eradication of infection with DAIR, five-year survival was similar to the primary THA group.

The DAIR group had inferior mean Oxford Hip Scores (OHS) compared with the primary THA group, but a significantly better mean OHS compared with the two-stage revision group.

Patients requiring only one DAIR for eradication of infection had a similar mean OHS to the primary THA group.

CITATION: Grammatopoulos G, Bolduc ME, et. al. Functional outcome of debridement, antibiotics and implant retention in periprosthetic joint infection involving the hip: a case-control study. Bone Joint J. 2017 May;99-B (5):614-622. PMID: 28455470. https://www.ncbi.nlm.nih.gov/pubmed/28455470

Case report supports in-office
diagnostic-needle arthroscopy

WILLINGBORO, N.J. – In-office diagnostic-needle arthroscopy is a cost-effective and reproducible procedure with potential cost and quality-of-life benefits for commercial payers and patients, according to a case report published in September in The American Journal of Orthopedics.

Its authors---including Sean McMillan, Lourdes Medical Center of Burlington County, Willingboro, N.J.---indicate that while further study of long-term cost savings for the health-care system is needed, significant value was realized in their 200-patient retrospective review.

That review indicates that minimum savings of $418 and $554.62 were realized for non-contrast knee and shoulder magnetic resonance imaging (MRIs), respectively, in independent facilities.

Those cost savings greatly increased in hospital-based facilities: $961.08 and $1,097.62, respectively, for knee and shoulder non-contrast MRIs.

The report’s take-home points are:

  • in-office diagnostic-needle arthroscopy is a minimally-invasive, rapid method for identification of intra-articular joint pathology

  • cost savings of a significant value can be realized to both the patient and health-care system via small-bore needle arthroscopy as opposed to MRI

  • diagnostic-needle arthroscopy can lead to quicker identification of pathology than MRI

  • diagnostic-needle arthroscopy can reduce the number of undue formal surgical diagnostic arthroscopies

  • standardization of image quality of small-bore arthroscopy may pose benefits to the variable quality of MRI

The researchers retrospectively reviewed patient charts for 200 in-office knee and shoulder diagnostic-needle arthroscopies performed by five surgeons over a 12-month period, and examined costs.

They point out that the procedure has a learning curve, and that the number of successful diagnoses will increase with training and repetition; data is not available on the number of procedures needed for proficiency.

CITATION: Sean McMillan, DO, FAOAO, Michael Schwartz, MD, MBA, et. al. In-Office Diagnostic Needle Arthroscopy: Understanding the Potential Value for the US Healthcare System. Am J Orthop. 2017 September;46(5):252-256. http://www.mdedge.com/amjorthopedics/article/145213/arthoscopy/office-diagnostic-needle-arthroscopy-understanding?channel=237

Sonography application backed
in hyaluronic-acid assessment

TEHRAN, IRAN – A recent study indicates that application of sonography might improve the response of patients to intra-articular injection of hyaluronic acid, at least in certain clinical indices.

The study published in August in the International Journal of Rheumatic Diseases compared the effect of sonographic-guided and blind-knee injection of hyaluronic acid.

Its authors---including Nahid Kianmehr and Atefeh Hasanzadeh, Iran University of Medical Sciences, Tehran, Iran---assessed 61 patients with primary knee osteoarthritis (OA) who were randomly-allocated into two groups and who received intra-bursal injections of hyaluronic acid over a three-week period.

The difference between baseline amounts of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale (VAS) score and these amounts after six and 12 weeks were calculated and subsequently compared between the two groups.

Among all scores and indices, WOMAC pain-and-function sub-scales changed significantly (both in the short-term and long-term follow-up).

The mean differences of WOMAC sub-scale pain in those who had received intra-articular injections under the guidance of sonography were significantly higher than those in patients who had received blind injections after six and 12 weeks.

The mean differences of WOMAC sub-scale function in those who had received ultrasonography-guided intra-articular injections were significantly higher than those in patients who had received blind injections after six and 12 weeks.

The mean in differences of the 10-cm VAS in the two groups was statistically significant after six weeks, but did not remain significant after 12 weeks.

CITATION: Nahid Kianmehr, Atefeh Hasanzadeh, et. al. A randomized blinded comparative study of clinical response to surface anatomy guided injection versus sonography guided injection of hyaluronic acid in patients with primary knee osteoarthritis. International Journal of Rheumatic Diseases. First published: 9 August 2017. http://onlinelibrary.wiley.com/doi/10.1111/1756-185X.13123/abstract;jsessionid=19E88F615D9E3A3917C6206B718C5941.f02t04

Research: No differences found
between anterior, posterior CSIs

BOSTON – Anterior corticosteroid injections (CSIs) and posterior CSIs significantly improved pain-and-function for up to six months, according to original research indicating that no differences were found between the two injections.

In the context of the study published in July in The American Journal of Orthopedics, CSIs combined with structured physical therapy (PT) produced significant improvement in pain-and-function in patients with subacromial impingement syndrome (SIS) regardless of injection route used.

The study’s authors---including Arun Ramappa, who is affiliated with Beth Israel Deaconess Medical Center (BIDMC), Boston---conclude that clinicians should rely on clinical acumen when selecting injection routes, as anterior and posterior are both beneficial.

The study’s take home-points include:

  • when conservative treatments for SIS don’t resolve symptoms, inflammation and pain can be reduced with use of subacromial CSI

  • both anterior and posterior CSIs significantly improved pain-and-function for up to six months

  • CSI combined with structured PT produced significant improvement in pain-and-function in patients with SIS, regardless of injection route used

  • clinical response to CSI may not depend on injection accuracy

The authors also note that while more research is needed to fully describe the role of CSI in SIS, their findings suggest that CSI using either an anterior or a posterior route creates a window of symptomatic relief in which patients may be able to engage in PT.

Of 55 patients enrolled in the study, 25 received anterior CSI and 30 posterior CSI.

Pain was measured with visual analog scale (VAS) scores and function with Single Assessment Numeric Evaluation (SANE) scores.

CITATION: Arun Ramappa, MD, Kempland C. Walley, BSc, et. al. Comparison of Anterior and Posterior Corticosteroid Injections for Pain Relief and Functional Improvement in Shoulder Impingement Syndrome. Am J Orthop. 2017 July;46(4):E257-E262. http://www.mdedge.com/amjorthopedics/article/145555/shoulder-elbow/comparison-anterior-and-posterior-corticosteroid?utm_source=Clin_AJO_onlineX_083117_F&utm_medium=email&utm_content=Postpartum%20Treatment%20of%20GCT%20|%20Trigger%20Digits


KNEE NEWS Vol.3 No.24

Extra care is recommended
for DM hip-reduction process

DURHAM, N.C. – Research published in The American Journal of Orthopedics recommends taking extra care when reducing hips with dual-mobility (DM) articulation and adopting a low threshold for general-anesthesia use in the presence of paralysis.

The case report published in May notes that acute intraprosthetic dissociation (AIPD) is a discrete entity, with sudden failure of a DM component within one year after implantation, and with AIPD characterized by dissociation of the femoral head from the inner articulation, resulting from impingement or closed reduction.

The researchers---including Mitchell R. Klement, MD, Duke Orthopedic Surgery, Duke University School of Medicine, Durham, N.C.---say more studies are needed to determine which patients with DM components are at highest risk, and which treatment is most appropriate.

DM components for total hip arthroplasty (THA) were approved by the U.S. Food and Drug Administration (FDA) in 2011.

DM-THAs are designed with an inner articulation between the femoral head and a larger polyethylene insert, and an outer articulation between the mobile polyethylene and a highly-polished metal insert to increase motion and minimize impingement.

Take-home points of the report, which describes the case of a non-demented 63-year-old man who developed AIPD three months after DM-component implantation, are:

  • AIPD of DM-THA is defined by dissociation within one year of implantation resulting from component impingement or closed-reduction maneuvers
  •  this is a distinct entity from late IPD (over a year) from implantation
  • a history of DM dislocation followed by subjective clunking, instability, and a series of more frequent dislocations should raise AIPD concerns
  • classic radiographic findings of AIPD include eccentric-hip reduction and soft-tissue radiolucency from dissociated-polyethylene component
  • AIPD practitioners should consider closed reduction with general anesthesia and sedation in the operating room to limit dissociation risk

CITATION: Mitchell R. Klement, MD, Elizabeth W. Hubbard, MD, et. al. Acute Intraprosthetic Dissociation of a Dual-Mobility Hip in the United States. Am J Orthop. 2017 May;46(3): E154-E159. http://www.mdedge.com/amjorthopedics/article/137771/hip/acute-intraprosthetic-dissociation-dual-mobility-hip-united-states

Research: Short-term prosthesis
decreases stress-shielding effect

WITTEN, GERMANY – A pre-clinical study developed to investigate design-depended differences of the stress-shielding effect after implantation of a selection of available short-stem total hip arthroplasty (THA)-prostheses led to the finding of a bone-stock protection in meta-diaphyseal bone by simulating a more distal approach for osteotomy.

The research results published in August in BMC Musculoskeletal Disorders demonstrated that implantation of a short-term prosthesis reduced the stress-shielding effect compared to implantation of a standard stem.

The results did not, however, confirm that the design of current short-stem THA-implants leads to a different stress-shielding effect with regard to the level of osteotomy.

The study’s authors---including Rene Burchard, University of Witten/Herdecke, Witten, Germany, and Sabrina Braas, Kreisklinikum Siegen, Siegen, Germany---also concluded that further clinical and bio-mechanical research including long-term results is needed to understand the influence of short-stem THA on bone remodeling and to find the optimal stem-design for a reduction of the stress-shielding effect.

The researchers used computerized tomography (CT) to generate a finite-elements (FE) model, and performed a virtual THA with different stem designs of the implant.
Stems were chosen by osteotomy level at the femoral neck (collum, partial collum, trochanter sparing, trochanter harming). Analyses were performed with previously-validated FE models to identify changes in the strain energy density (SED).

The authors found that in the trochanteric region, only the collum-type stem demonstrated a bio-mechanical behavior similar to the native femur.

In contrast, no difference in bio-mechanical behavior was found between partial collum, trochanter harming, and trochanter-sparing models.

All of the short stem-prostheses showed lower stress-shielding than a standard stem.

CITATION: Rene Burchard, Sabrina Braas, et. al. Bone preserving level of osteotomy in short-stem total hip arthroplasty does not influence stress shielding dimensions – a comparing finite elements analysis. BMC Musculoskeletal Disorders. 201718:343. Received: 17 April 2017. Accepted: 31 July 2017. Published: 7 August 2017. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017-1702-2

Medial-pivot pattern may not
tie in with post-TKA success

INDIANAPOLIS – A medial-pivot pattern may not significantly govern clinical success after total knee arthroplasty (TKA) based on intraoperative kinematics and modern outcome measures, according to a recent study indicating that further research is warranted to determine if a particular kinematic pattern promotes optimal clinical outcomes.

The study published in August in The Journal of Arthroplasty was designed to determine whether intraoperative medial-pivot kinematic patterns are associated with improved patient outcomes.

Its authors---including Lucian C. Warth, Indiana University School of Medicine, Indianapolis, and Marshall K. Ishmael, Indiana University Health Physicians Orthopedics & Sports Medicine, Indianapolis---performed a retrospective review of consecutive primary TKAs.

Sensor-embedded tibial trials determined kinematic patterns intraoperatively.

The center of rotation (COR) was identified from zero-to-90 degrees and from zero degrees to terminal flexion, and designated medial-pivot or non-medial pivot based on accepted criteria. Patient-reported outcomes were measured pre-operatively and at minimum one-year follow-up.

The analysis cohort consisted of 141 TKAs. Mean age and median body mass index (BMI) were 63.7 years and 33.8 kg/m2, respectively.

Forty-percent of TKAs demonstrated a medial-pivot kinematic pattern intraoperatively. A medial-pivot pattern was more common with posterior cruciate-retaining (CR) and posterior cruciate-substituting (CS)/anterior-lipped implants when compared to posterior stabilized (PS) TKAs.

Regardless of bearing type, minimum one-year Knee Society scores and University of California, Los Angeles, activity level did not significantly differ based on medial versus non-medial pivot patterns.

For patients with posterior cruciate-sacrificing implants, there were trends for greater median improvement in Knee Society objective and satisfaction scores in medial pivot knees.

CITATION: Lucian C. Warth, MD, Marshall K. Ishmael, BS, et. al. Do Medial Pivot Kinematics Correlate With Patient-Reported Outcomes After Total Knee Arthroplasty? The Journal of Arthroplasty. August 2017. Volume 32, Issue 8, Pages 2411-2416. http://www.arthroplastyjournal.org/article/S0883-5403(17)30221-8/fulltext

Study touts new glenoid option
for technical ease, simplicity

SAN FRANCISCO – A study published in July in The American Journal of Orthopedics indicates that Glenojetallograft is a new glenoid-reconstruction option that is technically easy and simple to perform in cases of glenoid-bone loss, while still creating an anatomical buttress with less surgical dissection than traditional coracoid-bone transfer.

Its authors---including Mia Smucny, San Francisco, and Anthony Miniaci, Cleveland Clinic Sports Health Center, Garfield Heights, Ohio---report that while short-term outcomes are reassuring, more research is needed for long-term graft follow-up and recurrent instability.

They note that anteroinferior glenoid-bone loss plays a significant role in recurrent glenohumeral instability, and that surgical strategies for reconstructing the glenoid in these cases include:

  • coracoid transfer
  • iliac crest autograft
  • allograft (osteochondral and iliac crest)

They report on this new technique for managing glenoid-bone loss, pre-shaped allograft, and describe surgical technique and outcomes; this allograft was implanted in 15 patients, and at short-term follow-up there are no known cases of recurrent instability or graft resorption.

The authors introduce the technique, in which a pre-shaped allograft (Glenojet; Arthrosurface, Inc.) is used to match the contour of the glenoid defect.

The graft is simple to insert and can reduce operative time.

Take-home points of the study are:

  • repair anterior bone defect on the glenoid related to recurrent anterior instability with pre-shaped, pre-drilled allograft
  • avoid graft-harvest complications related to coracoid (Latarjet) or iliac-crest autograft
  • simple guide system to allow for appropriate graft-and-screw placement
  • soft tissues can be repaired to the allograft in pre-drilled suture holes either inside or outside of the graft
  • position the graft without step at the anterior glenoid

CITATION: Mia Smucny, MD, Anthony Miniaci, MD, FRCSC, et. al. A New Option for Glenoid Reconstruction in Recurrent Anterior Shoulder Instability. Am J Orthop. 2017 July;46(4):199-202. http://www.mdedge.com/amjorthopedics/article/141690/shoulder-elbow/new-option-glenoid-reconstruction-recurrent-anterior?channel=295


KNEE NEWS Vol.3 No.23

Pre-operative pneumonia noted
as rare independent risk factor

CHICAGO – Original research published recently in The American Journal of Orthopedics includes findings suggesting that pre-operative pneumonia is a rare independent risk factor for adverse events (AEs) after hip-fracture surgery in geriatric patients.

The study published in May---whose authors include Daniel D. Bohl, Rush University Medical Center, Chicago---also indicates that underweight body mass index (BMI) is predictive of death in these patients who present with pneumonia, while early surgical repair doesn’t appear to be associated with adverse outcomes.

The researchers conclude that further investigation is warranted to determine if such patients benefit from specific pre- and post-operative strategies for optimizing medical-and-surgical care based on their findings.

The study was based on a retrospective cohort of geriatric patients with operatively-treated hip fractures from 2005-to-2012 identified in the National Surgical Quality Improvement Program data-base.

Pre-operative pneumonia was present in 82 of 7,128 geriatric hip-fracture patients identified, and was associated with:

  • male sex
  • transfer status
  • functional status
  • pre-operative anemia
  • confusion
  • dyspnea at rest
  • chronic obstructive pulmonary disease

Take-home points from the study are:

  • the prevalence of pre-operative pneumonia is 1.2% among hip-fracture patients over 65
  • pre-operative pneumonia is an independent risk factor for mortality and AEs, including renal failure, prolonged ventilator dependence, and prolonged altered mental status after geriatric hip-fracture surgery
  • underweight BMI (less than 18.5 kg/m2) is associated with higher mortality within 30 days among hip-fracture patients admitted with pneumonia
  • the mortality rate normalized to that of patients without pneumonia within two weeks of hip-fracture surgery
  • time from admission to surgery was not associated with AEs or mortality among hip-fracture patients admitted with pneumonia

Also: A study published in July in Osteoporosis International suggests that abdominal obesity as measured by waist circumference and waist-hip ratio might be associated with an increased risk of hip fracture. The study can be accessed at https://link.springer.com/article/10.1007%2Fs00198-017-4142-9


CITATION: Joseph T. Patterson, MD, Daniel D. Bohl, MD, MPH, et. al. Does Preoperative Pneumonia Affect Complications of Geriatric Hip Fracture Surgery? Am J Orthop. 2017 May;46(3): E177-E185. http://www.mdedge.com/amjorthopedics/article/138770/hip/does-preoperative-pneumonia-affect-complications-geriatric-hip

Research: Use of opioids before TKA
yields less pain relief from operation

BOSTON – Patients who use opioids before total knee arthroplasty (TKA) obtain less pain relief from the operation, according to a study indicating that clinicians should consider limiting pre-TKA opioid prescriptions to optimize the procedure’s benefits.

The study published in May in The Journal of Bone & Joint Surgery---American Volume was designed to assess pain relief achieved by TKA in patients who had and had not used opioids before their surgeries.

Its authors---including Savannah R. Smith, Brigham and Women's Hospital, Boston, and Jennifer Bido, Harvard Medical School, Boston---augmented data from a prospective-cohort study of TKA outcomes with opioid-use data abstracted from medical records.
They collected patient-reported outcomes and demographic data before-and-six-months-after TKA, using the Pain Catastrophizing Scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Their cohort included 156 patients with a mean age of 65.7 and a mean body mass index (BMI) of 31.1 kg/m (standard deviation [SD] = 6.1 kg/m); 62.2% were female.
Pre-operatively, 36 patients had obtained at least one opioid prescription. The mean-baseline WOMAC pain score was 43.0 points (SD = 12.8) for the group not using opioids before TKA and 46.9 points (SD = 15.7) for those who had.

The mean pre-operative Pain Catastrophizing Scale score was greater among opioid users (15.5 compared with 10.7 points among non-users).

Adjusted analyses showed that the opioid group had a mean six-month reduction in the WOMAC pain score of 27.0 points, compared with 33.6 in the non-opioid group.


CITATION:  Smith SR, Bido J, et. al. Impact of Preoperative Opioid Use on Total Knee Arthroplasty Outcomes. J Bone Surg. Am. 2017 May 17;99(10):803-808. PMID: 28509820. PMCID: PMC5426402  [Available on 2018-05-17] https://www.ncbi.nlm.nih.gov/pubmed/28509820


Clinical review details benefits
of military knee-treatment efforts

SAN ANTONIO – A recently-published clinical review notes that complex knee restoration for injured soldiers follows a similar paradigm as for high-end civilian athletes---and offers complex-knee injury guidelines.

The review published in July in The American Journal of Orthopedics notes that military treatment involves patient transportation, significant rehabilitation, and time away from work and family; it concludes that anything that helps patients return to normal function is highly desirable.

Study author Thomas M. Deberardino, San Antonio Orthopaedic Group, reports that the globally-integrated military health-care system allows most pre-operative work-up to be performed at duty stations, and lists these take-home points:

  • thorough pre-operative planning is imperative, and inclusive of history, physical examination, radiographs, and magnetic resonance imaging (MRI) and, potentially, computed tomography (CT) scans
  • plan carefully for needed graft sources
  • rehabilitation starts pre-operatively; a detailed individualized plan is often warranted
  • indicated ligamentous or augmented repair with reconstruction is more likely to succeed when performed within two weeks of injury
  • complex combined knee-restoration surgery can be safely performed in an out-patient setting

Dr. Deberardino relates the case of a serviceman whose successful knee-restoration treatment was streamlined from two overseas trips to one, and offers these guidelines:

  • at each decision point, determine whether knee and patient can withstand intervention
  • after deciding to proceed with restoration, list meniscus, cartilage, and ligament injuries to be addressed
  • determine warranted repairs (meniscus, cartilage, ligament); repairs generally are best performed within seven-to-14 days
  • determine which ligament injuries warrant reconstruction
  • rank-order ligament-reconstruction requirements; reconstructions can proceed if cases move smoothly, if there are no developing tourniquet-time issues, and if soft-tissue envelope responds as expected
  • consider autograft and/or allograft tissue needs for concomitant or staged meniscus and cartilage-restoration options/requirements


CITATION: Thomas M. Deberardino, MD. Applying Military Strategy to Complex Knee Reconstruction: Tips for Planning and Executing Advanced Surgery. Am J Orthop. 2017 July;46(4):170-175, 202. http://www.mdedge.com/amjorthopedics/article/141673/knee/applying-military-strategy-complex-knee-reconstruction-tips?channel=237

Study focuses on the importance
of assessing prevalence of GJH

ODENSE, DENMARK – Generalized joint hypermobility (GJH) and GJH including shoulder hypermobility (GJHS) are frequently self-reported musculoskeletal conditions in the general adult population, according to a study indicating that, compared with non-GJH (NGJH) and especially GJHS, present with higher odds ratios (ORs) for upper-body musculoskeletal symptoms, more severe symptoms, and decreased health-related quality of life (HRQoL).

The study published in May in BMC Musculoskeletal Disorders indicates that there is a need to study the prevalence of GJH, including lower-extremity hypermobility and the association to lower-body musculoskeletal symptoms.

Its authors---including Birgit Juul-Kristensen and Lasse Østengaard, University of Southern Denmark, Odense, Denmark---add that since their study is cross-sectional, longitudinal studies are recommended to describe the onset, fluctuations and persistence of chronic musculoskeletal symptoms and osteoarthritis (OA) in the general adult population, and how musculoskeletal symptoms are associated with GJH through the life course.

Their research included 2,072 participants, aged 25-to-65, randomly extracted from the Danish Civil Registration System; 1,006 responded to questionnaires.
Compared with NGJH, participants with GJH and GJHS had ORs of 1.5-to-3.5 for upper-body musculoskeletal symptoms within the last 12 months (mostly shoulders and hands/wrists).

GJH and GJHS also had ORs of 1.6-to-4.4 for being prevented from usual activities, mostly due to shoulder-and-neck symptoms.

GJH and GJHS had ORs of 2.2-to-3.1 for upper-body musculoskeletal symptoms lasting for more than 90 days (neck, shoulders, hand/wrists) and 1.5-to-3.5 for reduced HRQoL (all dimensions, but anxiety/depression) compared with NGJH.

Generally, most ORs for GJHS were about twice as high as for those having GJH alone.


CITATION: Birgit Juul-Kristensen, Lasse Østengaard, et. al. Generalised joint hypermobility and shoulder joint mobility, - risk of upper body musculoskeletal symptoms and reduced quality of life in the general population. BMC Musculoskelet Disord. 2017; 18:226. Published online 2017 May 30. PMCID: PMC5450151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450151/


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