Episode Transcript
[00:00:02] Speaker A: Welcome to your Cases on Hold, the JVGS podcast hosted by Andrew Schoenfeld and Aisha Adkeen.
[00:00:08] Speaker B: Here we discuss the best of what each issue of JBJS has to offer with the usual dose of entertainment and pop culture.
[00:00:16] Speaker A: Take us with you in the gym, on the commute, and as ever, whenever your case is on hold.
Welcome back everyone to your Case is on hold. This is episode 109.
If you are listening on the day we Release, it is June 30. For July 1 issue of JB JS, we are covering the best that there is, research and everything new, exciting and human interest in the area of orthopedics. In the heat of the summer, as always, the lawyers want us to be sure to tell you that what we cover here is the opinion of the co hosts and not reflective of journal policy, the editor in chief, the editors of the constituent journals, the board of trustees, the people who work at JBJS corporate. This episode of your Case on Hold is brought to you by jbjs, CME and Clinical Classroom. One stop shopping for everything that you need in education in orthopedics. You're listening to us. You're reading the journal. Make the most of it. Get credit. Get CME for the work that you're doing. For those who are regular listeners, you already know, but for those who may be new, I am Andrew Schoenfeld, professor of Orthopedic Surgery and Vice Chair of Education at Harvard Medical School. And I have across the way.
[00:01:45] Speaker B: Hi everyone. I'm Aisha Abdeen. I am an associate professor of Orthopedic surgery and chief of the Division of Hip and Knee Arthroplasty at Boston Medical Center.
[00:01:55] Speaker A: All right, so moving forward, we have top of the pile here.
We have Charles H. Epps Jr. Maryland.
1930 to 2026.
And that is an obituary that is permanently free.
We have what's New in Orthopedic Trauma by Padu Bidri, also permanently free.
First, do no harm revisiting the Hippocratic tradition from Dr. Constantinos Melizos, former member of the editorial board and in Greece. So someone who is revitalizing and revisiting the Hippocratic tradition from its roots. Essentially. This is the lead article for this issue. It is 30 days free from hip and knee to shoulder. Is the Obesity Paradox Becoming a Surgical Reality by Kunitzor, Permanently free.
Then we have Fellowship Directors Forum Strategies for the Management of a Struggling Fellow by Fishman, followed by Interbody Cages, Surface Technologies in Spinal Implants by Nasser.
Next is Insights into evolving trends and controversies in orthopedic surgery from the ABOS case collection system. Data from current procedural terminology specific special questions 2022-2024 by Guyton with a comment.
Then last in this part of the pile Increased critical shoulder angle impairs tendon bone healing in a rat model of chronic rotator cuff tears. Some basic science. Good for your soul, that is. By Long and colleagues with a comment.
We're now moving into the headlines.
What's new in orthopedic research this week my headline is Cost effectiveness of surgery versus functional bracing for humeral shaft fractures in adults. A pre specified economic evaluation of the finish shaft of the humerus abbreviation FISH trial.
This is by Suter and colleagues with a comment and a highlight and a visual summary and also permanently free. So we got all the bases covered. That's right on that front.
So this is an interesting cost effectiveness analysis that was a pre specified secondary study component of the finished shaft of the humerus Trial.
This study was a randomized clinical trial at two Finnish university hospitals conducted over six years, wrapping up about eight years ago.
They included 82 adults with an average age of about 49 with displaced closed humeral shaft fractures who were randomly assigned to surgical fixation in 38 individuals or functional bracing in 44 individuals. The primary outcome was the incremental net monetary benefit in euros based on quality adjusted life years measured with the 15 dimensional instrument analyzed from both a societal and healthcare perspective.
It's an interesting approach. Most of the time the most familiar cost effectiveness analyses are really looking at things through the healthcare perspective. I think that that is the most logical essentially, especially since most of our insurance relationships in the medical system in the US and obviously if you have governmental payers in Europe, it's typically the health care insurance or the organization that is kind of shouldering the cost for these for these treatments. But they also want to kind of look at it from the societal perspective.
And the factors that come into the societal perspective, they can vary from burden on other family members or time out of work, which is really the seminal piece here, is the time off of work, particularly when you're talking about a population with the average age of 50, so you know, prime working years, lost productivity, time off of work.
In neither one of these, of course, does it really factor into the desires of the individual, you know, wanting to avoid surgery want or and the associated risks versus functional bracing and the challenges that may come with that. It's not always working with a sarmiento brace.
My dad actually had a humeral shaft fracture after his fall.
And it's not so simple as just walk around with a short arm cast like a green stick fracture in a, in a 8 year old.
[00:06:58] Speaker B: Like absolutely no. It's hard to sleep. Everything is difficult with a hemophage.
[00:07:03] Speaker A: So, you know, definitely some things to consider here. And the study is well done for sure.
It was a well done randomized trial and they cover all the basis for the cost effectiveness analyses. The points that I have are really just kind of stylistic and in terms of the interpretation.
So they found that from a societal standpoint and this is what they lead with, surgical treatment was both more effective and less costly than bracing. And that solely.
They don't provide the caveat really until you dig for it. But that's really solely due to the amount of time that individuals had to spend out of work. That's it.
That's a cost that the insurance company doesn't see that the, you know, maybe the family does or doesn't see. Obviously in terms of, you know, depends on the nature of the work as well.
And from a health care perspective though, and this is really where the tension is, the functional bracing was less costly, therefore more cost effective.
So when you're considering only direct medical costs, surgery was unlikely to be cost effective at thresholds below €80,000 per quality. You know, obviously the conversion of the euro to the dollar fluctuates, you know, over time, but it's generally somewhere in the range of like A$10 to A$20, maybe to a euro, something to that effect. So I mean, these are approximate to dollars essentially. And we're typically now looking at, you know, most people accepting the, that classic $50,000 per QALY threshold is quite antiquated. I think really in the modern constructs, you're looking at anything under 150 per qaly is generally pretty well accepted as being cost effective.
So when they're saying that 75% probability of cost effectiveness only at €120,000 or you know, a little bit more, it's still going to be under the, the 150, I think in terms of cost per quality. So then there's the, you know, it always like when I see these, the study and then the conclusions you're, I'm always thinking about like, so which one of the authors really had a vested interest in making sure that like one of these choices was not like foundationally or fundamentally disqualified? Or maybe it was a reviewer or editor that was like, you can't just based on this. But you know, they go through all this. And then they say surgery is cost effective when societal costs are considered, but functional bracing remains a reasonable option, particularly for patients less affected by time away from work. Well, what I would say there is actually, particularly for patients who don't want a surgery, who don't want a big gash on their arm and have to undergo the, the pain of the surgical intervention, the risks associated with the anesthesia, you know, even if it is they're not using general anesthesia or certainly if they are, you know, most of this gets into more of an academic conversation. At the end of the day it seems to me that the less expensive, probably better, except in select situations, is to go with the non operative option.
And I think that that was, you know, I'm inferring here a little bit, but just looking at, you know, what they're saying and how things look, that's, that's really what it's going to come down to in a healthcare system with resource constraints, which that's every health care system. I think an initial non surgical approach reserving surgery for non union or delayed healing may they say may be preferable. I think that is preferable.
And then because quality of life did not differ substantially between the two treatments, indicating that the choice of treatment should be guided by individual circumstances and priorities. And there's the caveat to keep the door open. We're not shutting the door on surgery. You got it. You got to talk to folks about it. And I mean that is true. And there may be some individuals, I mean certainly like if you're talking about a, say like a soccer goalie or something like that. Right. Like the ability to play is their livelihood. So yeah, probably in those situations going with the surgery is, is really going to make sense for them to accelerate the rehab. And when they can't play, they're not earning.
You know, maybe any kind of professional athlete probably, but outside of that realm, I think that this is, it's being characterized as more of like a objective than it probably needs to be, particularly since from the healthcare perspective, bracing is cost effective as compared to surgery. Right.
[00:11:58] Speaker B: But I guess it depends on whether you're looking at the whole societal approach versus the individual. And at the end of the day this information is helpful, but when it comes down to is that we're managing patients on an individual basis and that's what it really, what really matters. And you know, what I liked about this paper is that it makes me appreciate how JBGS has become so international in scope. They use this centralized work absence registry and we don't have anything like that in the U.S. they have that in Finland and we'll be able to conduct such a study here with reliable data on work absences. So I just thought that was kind of fascinating in and of itself.
I thought it was well conducted, but in the end of the day I agree with you. It really does come down to the individual patient as opposed to making these sweeping generalizations based on what society needs versus the individual.
[00:12:44] Speaker A: Couldn't agree more. So let's see what you have to say about your headline Minimal Movement restrictions do not increase hip dislocations following total hip Arthroplasty A before and after study of 10,357 patients by Claassen and colleagues with a comment infographic and permanently free
[00:13:05] Speaker B: yeah, this study was performed in the Netherlands and it was done in order to evaluate the importance of movement restrictions, AKA hip precautions after total hip arthroplasty.
Hip precautions were historically quite ubiquitous. When I trained, all patients were given hip precautions after a total hip There was a concern that movements including deep bending with internal rotation were unsafe and could result in dislocation and bending more than 90 degrees. Putting shoes on, socks on, going to the bathroom are considered risky, so it was common to prescribe graspers to pick up items on drop floors done on dopping shoes to use elevated commodes in the bathroom, et cetera. But since that time our surgical techniques have improved. Approaches are less invasive with less muscle dissection regardless of approach.
Implant design has allowed us to use larger heads and we have a better understanding of the hip spine relationship and its impact on dislocation and all of which reduce dislocations and so the native precautions have come into question. Also with the focus on patient satisfaction, it's identified that having precautions has a negative impact on satisfaction and that was the reason in this study that the authors implemented the protocol change. They had multiple hospitals within this system in Holland where they implemented a high value healthcare initiative much as what we have here regarding cms and they found that patients were dissatisfied with precautions. So they implemented this and they compared the patients that had precautions historically to those that had the new protocol and patients had surgery between 2015 and 2020. In one of seven participating hospitals. Patients were excluded if they were less than 18 years old and other diagnoses other than hip osteoarthritis is the indication for total up arthroplasty.
They were assigned to one of the two groups according to the protocol based on the time of their surgery. They received six strict instructions to avoid bending the hip past 90 degrees of flexion, twisting the leg in or out, adducting the hip over the midline, sleeping on their side, crossing their legs and putting socks or shoes on independently, and were instructed to walk with crutches for six weeks, to sleep on their back or to sleep on their side with a pillow between their legs and to use elevated chairs and elevated toilet seats.
Patients in the minimal movement restricted group either were prescribed no restrictions and instructed to move as able or they were prescribed minimal movement restrictions. These restrictions included avoidance of movement that involved a combination of hip flexion with internal rotation and abduction such as crossing their legs while sitting, but patients were otherwise encouraged to move as able or move as your pain allows.
Assistive devices such as crutches, pillows, elevated chairs were not mandated but could be used for comfort according to patient preference. In that group, the authors corrected for confounders including age, BMI, femoral head size, which included 22 millimeters, 28, 32 and 36 millimeter heads and surgical approach and in this series included posterior, lateral, anterior and anterolateral. The authors performed five sensitivity analyses to adjust for posterior approach, surgical fixation type and the effect of the year of surgery, and a propensity score analysis to correct for potential biases due to differences between the two groups with regard to age, BMI, femoral head size and surgical approach.
They had 10,357 patients.
The seven hospitals changed protocol on different dates and one hospital didn't change protocols at all, so their patients were included in the strict precautions only group.
Approximately 75% of patients had strict precautions and only 25% had the minimal precautions.
The majority of patients actually had a posterior approach and a 32 millimeter head in both groups.
A greater percentage of patients in the restricted group had an anterior approach, 24% in the restricted group and 15% in the minimally restricted group.
The incidence of early dislocation in 90 days was not statistically different between both groups. There was 1.93% in the minimally restricted group and 1.46% in the restricted group.
Statistically there was a lower odds of dislocation was found for female sex, 32 millimeter femoral head versus the smaller heads and a direct lateral approach compared to posterior lateral approach. The numbers needed to treat analysis showed 213 patients needed to be prescribed strict movement restrictions to prevent one dislocation for the sensitivity analysis for posterior approach, the dislocation rate was 2.03 for minimally restricted group and 1.5 in the restricted group with a number needed to treat of 188 patients to prevent one dislocation.
The authors conclude that the prevention of such few dislocations may not outweigh the discomfort and delayed recovery of a larger number of patients.
So their findings reflect other studies that suggest no significant change in dislocation risk with reduced mobility restrictions. The Danish registry also showed that there may be a potential benefit for restrictions in heads that are smaller than 28 and 32, but not for other confounders such as age or approach. Also, now many surgeons are using a direct anterior approach, and the use of precautions anecdotally is quite low. Many of us that still use some form of restrictions do it on the basis of orthopedic dogma. I still use hip precautions in my posterior approaches, or at least a modified version of that, and no precautions for my direct anterior, despite using 36 millimeter heads and sometimes even 44 millimeter heads nowadays.
But perhaps the emerging literature says that we should throw all caution to the wind and in doing so, we would be more evidence based.
I think this is an instance where we can call upon the 1990s wisdom and philosophy of the Big Lebowski, which I know you love, Andrew. I know you often talk about research nihilism, and there is no role for that, to which I agree.
However, if you recall the fight scene at the very end of the movie where one of my favorite characters, the John Goodman character, Walters, says reassuringly to Donnie, no, Donnie, these men are nihilists. There's nothing to be afraid of. So perhaps we can practice hip precaution nihilism. And perhaps there is nothing to be afraid of after all.
What are your thoughts?
[00:19:10] Speaker A: I love the tie in, and I have a rejoinder for that, because he assures Donnie there's nothing to be afraid of from these nihilists, and then Donnie dies.
[00:19:22] Speaker B: I know, that's the horrible part, right?
[00:19:26] Speaker A: So the first thing that I thought was interesting is this before and after study.
I think it's more conventionally a pre post. You know, I was looking at it, I'm like, are they saying it's somehow different from a pre post? But in looking at their table one, I think it's just. It's a pre post.
[00:19:41] Speaker B: Yeah.
[00:19:42] Speaker A: Yeah. So here's the part where maybe Walter should have let Donnie be a little bit more scared of the nihilist.
Because what I want to point out here is, you know, they're doing a logistic regression analysis. They're accounting for the, you know, confounders. Differences in case mix, maybe even secular trends to some degree across the two time based populations. And they say, correctly that there is no significant difference statistically in the odds of early hip dislocation between the two groups. And they recognize there is a point estimate that suggests a 25% higher odds of dislocation in the minimally restricted group. But then they say, but the difference wasn't significant. And that is true. But that's still a 25% increase.
[00:20:30] Speaker B: Right.
[00:20:31] Speaker A: And that's non negligible. So the fact that it's not significant has to do with the dislocation rate and the overall characteristics of the sample. If you had. All that's going to change at the end of the day is the confidence interval. So blow this up to, you know, a population 10, 20 times and that confidence interval might be 1.25 with a 1.10, 1.6, and then it would be significant.
[00:21:01] Speaker B: Agree.
[00:21:02] Speaker A: So, you know, I think that the take home points here are, you know, yes, it's, you need to treat a lot of patients who probably don't need the restrictions to avoid that unpredictable adverse event. But particularly with the posterior ones, it's just so catastrophic for everyone involved.
And it seems to me, again, as everyone knows, and I've said before, not someone who does these in my practice, but obviously saw them in training. And every so often, because my practice intersects so nicely with patients with hip spine syndrome, I see patients who are dealing with the fallout. It's the best chance to get it right is the first time. And once it dislocates, it's just never the same. Right, exactly right.
[00:21:46] Speaker B: Devastating complication. I agree.
[00:21:48] Speaker A: I think it makes sense just physiologically and anatomically from the posterior standpoint, since we cannot, you can talk about minimal minimizing, but you can't talk about eliminating the risk.
[00:22:01] Speaker B: Yep, exactly.
[00:22:02] Speaker A: And with some of these, you know, I, I remember too in training, like we would put the patient in the foam thing and strap them down before they even like woke up. Like the, the A frame foam thing. Spacer.
[00:22:15] Speaker B: Yeah, yeah. I used to use that in the beginning of our practice and in residency as well. But you know, just now with larger heads because the polys have become so much more resistant to wear, we're allowed to use these larger heads. We're getting into 36, 40 millimeter heads. They didn't even have that in this particular study. And so I think regardless of approach, the likelihood of dislocation has gone down
[00:22:35] Speaker A: considerably just from like a soft, like from a posterior approach. It still just Makes sense to me in terms of what you're cutting and where the stabilizers are. And you know, an ounce of prevention is a pound of cure, so.
[00:22:50] Speaker B: Exactly right. And I don't think patients are that dissatisfied by having to have precautions of time, you know. Yeah, subjective.
[00:22:59] Speaker A: Okay. All right.
Another joint arthroplasty paper featuring in the your cases on hold featurette, Microbial resistance patterns and periprosthetic joint infection of the knee. A 24 year longitudinal study by Guo and colleagues with a comment.
This is a highlight article for this issue. There is an infographic and it is 30 days free, so definitely check into it. This is a study that was conducted on Data collected over 24 years, essentially from the year 2000 to 2023, including 487 first episode periprosthetic joint infections following primary total knee arthroplasty. There were three tertiary hospitals contributing to this data from New Zealand.
The study is essentially a clinical epidemiology describing the changes in the infectious organisms.
I was particularly interested in looking at resistant PGI cases and then the breakdown amongst the common pathogen groups.
There were a total of 487 PGI cases with 608 culture specimens identified.
The mean patient age was 70 and the mean BMI was 33. So for the purposes of translation, I'd say that that's pretty good. That's I think comparable to certainly the type of patients who may be undergoing these type surgeries in the US.
54% of the population had ASA of 3 or higher.
About a quarter were diagnosed with diabetes. The mean follow up was seven plus or minus five years, which is a pretty broad range of course, particularly since they're talking about the study including patients for potentially 24 years of surveillance.
The meantime to the first PGI treatment was 4 plus or minus 7 years.
Really quite long. And that obviously colors some of their conclusions that we'll get into.
The first thing and what they were really intending to look at is the proportions of resistant PGI cases and this remained consistent over the 24 years in the range of essentially 20 low 20%, 19 to 24%. These were comparable for the four most common pathogens as well. And that was staph aurease, coagulative negative, staph, strep and gram negative organisms.
The most common gram positive organisms were staph aureus, 30% coagulase negative staph species which they abbreviate as cons in 20%. I like the cons thing. It's like, you know, they're they're loose, they're escaped.
And then strep species also at 20%. The most common gram negative was E. Coli in 33 cases, 5%, which is also very interesting. Also, you know, for some of these, the source of the origin, you know, might. Might play in. I was reading something recently in a, in a spine article where they actually postulate that low flow states to the intestines associated with hypotension during surgery creates increased permeability across the gut blood barrier, which then allows the E. Coli that's living there to kind of get into the bloodstream.
Obviously, because the, the knee is distal to the parts of the body that expel E. Coli, there can be sort of a showering effect or something like that as, as well.
But, you know, I, I thought that that's just an interesting thing that came to mind as I was reading this. The one thing, you know, in terms of their retrospective and their clinical epidemiology on this front, inarguable, this is their experience.
How their experience might translate to somewhere else, you know, is kind of open to question. But as I said, I think there's good fidelity, at least in some of the metrics. The one part that I was a little bit like, hold up here, is that they say time less than one year since the process was implanted was the most important risk factor for both polymicrobial infections and resistant infections. And that's not, to my mind, really characterizing what is a risk factor appropriately. I would say that this is more of like, if somebody shows up with an early knee infection, it is an indicator. It is a, it is a flag that, that this may be a more virulent as compared to somebody who's showing up at their average four or five years down the road. Where, you know, what are the etiologies for that they had some transient bacteremia or something like that, and then it seated the. The source. So, you know, early infections are, are highlighted as the bad actors. But the time, it's not the time itself. It's not that you have the surgery and the polymicrobial infections are just really have the potential to get in there. It's just that they show up so much sooner and they're. Those really bad infections are more likely to occur, I think, as a result of the surgical site infection, the surgical event itself then, than they are to show up in a healed, stable prosthesis for a long period of time. They said the incidence of polymicrobial infections decreased over the study period. I was Surprised by that more recent revisions were associated with lower odds of polymicrobial infections.
So again their emphasis is that the resistance profiles remain stable. Also surprised by that, they say this supports a recommendation for the prompt administration of broad spectrum antibiotics with or without the addition of gram negative agents in early PJIs.
Combined therapy with vancomycin and a gram negative agent is advised for all early PJIs. Vancomycin is the first line. Empirical therapy for acute knee PGI is further supported by the high incidence of those cons and antibiotic resistance previously observed in these early infections. Those last three statements, those are all non sequiturs. That's just their hypothetical theoretical inference. It's not tested or informed by anything that was done in this work.
That along with characterizing the time to infection as a risk factor, which to me doesn't really make sense in terms of the conceptual model of how infections themselves develop, are the only somewhat false notes in what otherwise I think is both a solid work of clinical epidemiology and probably with details that are testable in my information.
[00:30:07] Speaker B: Yeah, I agree. I think this was really interesting from an epidemiological standpoint because I think we would have all guessed that the resistance would have gone up over these timeframes. Certainly it's reassuring that it stayed the same, but it's still pretty high. 20% resistance is quite high, so it's still a cause for concern. I agree with you. My biggest beef with this paper was their drawing of clinical conclusions that they didn't prove right. They talk about what antibiotics should remain effective and they use those words. But we don't know what effective treatment was here. We only know what these organisms were resistant and sensitive to. So they should have stated it that way. I think they're overstating their findings about clinical effectiveness when they don't have that data here because we don't know how the patients did.
[00:30:50] Speaker A: Right.
[00:30:51] Speaker B: That makes sense.
Great.
[00:30:54] Speaker A: All right.
[00:30:55] Speaker B: Bold or not?
[00:30:57] Speaker A: No, no, not, not Unbolt.
Let us get into the honorable mention at this point. This is cefazolin and the R1 side chain. Why patients with a cephalosporin allergy can be safely given cefazolin while undergoing joint arthroplasty, which just plays into the stereotype of orthopedic surgeons obsession with Ancef.
So this, this study reviewed the records of 1268 patients who had a documented cephalosporin allergy and underwent total hip or knee arthroplasty at a high volume academic center which was HSS from 2016 to 2024.
They compared patients who received cefazolin despite the cephalosporin allergy. They're like, allergies be damned.
We're going with cefazolin. And the patients who received an alternative antibiotic prophylaxis, which is about twice the number.
The primary outcome was the incidence of IgE mediated allergic reaction or severe type 4 hypersensitivity reactions with end organ dysfunction within 72 hours.
And then the secondary outcomes were 90 day. Complications primarily focused on PJI or adverse events related to the antibiotic. The incidence of an allergic reaction to a patient with an allergy to cephalosporin who received cefazolin was 00 of 482, compared with 0.5, 0.5% 4 of 786 in patients who received an alternative antibiotic prophylaxis. There was no significant difference in the rates of PGI after primary arthroplasty.
And their conclusion? Cefazolin administration in patients with a cephalosporin allergy was associated with a 0% incidence of IgE mediated or severe type 4 allergic reactions. Of course, as we've said before, nothing is never, nothing is always. You do this enough, somebody's gonna have a response. And I don't know how that would look. It was if, like, giving them cefazolin when they have a cephalosporin allergy. Like,
[00:33:06] Speaker B: question.
[00:33:07] Speaker A: Yeah, yeah, I don't know that the risk, the risk mitigation, you know, the risk management folks are like, so it said on the chart that they had a cephalosporin allergy and you gave them cephazolin anyway. You're like, yeah, but I got this article from HSS that says that it's totally cool to do that.
They send it zero. It happened. Zero.
[00:33:31] Speaker B: Yeah, I know, but based on previous studies, one large study out of the Mayo Clinic showing that if we don't give Ancef, then patients do have a 30% higher chance of getting a PGI. So people are really sticking to their guns and trying to give cevalazolin whenever able, but it has prompted many of us to do allergy testing in that situation.
[00:33:51] Speaker A: Yeah, I mean, there is a JAS review article that there's a algorithm that you work through and it's like, delay the surgery to do the allergy testing, then you confirm it and then you're really in. In a good place.
Yeah, I think that's a better approach than just relying on this article to kind of get into some things that, you know, if you use it enough, you swim with sharks at some point.
Yeah. So that's about all the time that we have for this episode.
Thanks for taking the time to listen to what's new and exciting in orthopedics in this first half of July. Come back in the second half and Dr. Abdeen will be leading us in some incredibly interesting articles. Dynamic discussions ahead.
Stay tuned. And hopefully where you are in the middle of the summer, your cases are ready to go. We liked all the articles today, I think, but here things are still on hold.
Let's be real.
[00:34:58] Speaker B: Thanks, everyone.
