Episode Transcript
[00:00:03] Speaker A: Welcome to your Cases on Hold, a JBJS podcast hosted by Antonia Chen and Andrew Stonefield.
[00:00:10] Speaker B: Here we discuss the science of each issue of JBJS with an additional dose of entertainment and pop culture.
[00:00:17] Speaker A: Take us with you in the gym, on the commute, or most certainly whenever your case is on.
[00:00:28] Speaker B: Welcome back to another episode of your Cases on hold, episode number 98.
Welcome to the new year 2026. Great to have all of you here.
As we all start off today, I'd like to introduce ourselves. I'm Antonia Chen, Executive Editor at jbjs, and I have here with me I'm.
[00:00:49] Speaker A: Andrew Schoenfeld, Associate Editor for Methods at jbgs.
[00:00:54] Speaker B: And we also have a guest visitor here today. Please introduce yourself.
[00:00:58] Speaker C: Hi, I'm Aisha Abdeen. I'm an arthroplasty surgeon at Boston University and Chief of the Division of Hip and Knee Arthroplasty at Boston Medical Center.
[00:01:07] Speaker B: Thank you so much for joining us. We really love having you here.
As always, these opinions are our own. They don't reflect jbjs, the JBJS editorial board, or anyone else affiliated with this.
Now that said, this is sponsored by the Miller Review Course. If you haven't got to check it out yet, go get your learn on. There's so much more information at the Miller Review course. Whether you're studying for an exam, whether you want some good orthopedic information, the Miller Review Course is a great place to go.
So without further ado, we're going to start with our top of the pile. What's New in Adult Reconstructive Knee Surgery by Luo et al. And it's permanently free. Your hospital says no to innovation. Here's how to change that. But Hamid, some good information there to talk about what you want to do in your own hospital setting. Am I that guy?
By Bernstein? It leaves the mystery there for you to go read it.
[00:01:56] Speaker A: You are that guy.
[00:01:58] Speaker B: Bottom line, now it's a question. Am I that guy? So there you go. Disconfirmation bias may exist in all of us, but being aware is the first step towards critical thinking. By Sahu Global Orthopedic Education. Doing More with Less by Robbins. And it's permanently free.
Pause and Appreciate by Nelson. It's also permanently free Through Their Eyes, Doctors or Monsters by Zao. Also permanently free Trauma and orthopedic surgery. The Spanish model by Rojas Sayol is permanently free. And it's the highlight of this one. So please go check it out. Without further ado, we're going to start with our headlines, Dr. Schoenfeld is going to talk about incidence, characteristics and management of concomitant ipsilateral upper extremity fractures in in pediatric montasia fracture dislocations. A 13 year single institution case series by Amaral et al.
[00:02:51] Speaker A: Yes. So we'll introduce the new Shears sitcom paradigm.
Some foreshadowing there. This is a retrospective review conducted at a single academic center. So we're really getting what I think is the Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. 13 year experience with these concomitant ipsilateral upper extremity fractures in pediatric montagia fracture dislocations.
They maintain that these are rare, poorly characterized, may be missed during initial evaluation.
In this study, they aim to evaluate the incidence characteristics and management of these types of injuries.
The study was conducted on data collected from 2011 to 2024.
In the purest sense, you don't know what you don't know.
So I don't think that, you know, they could have missed some too.
At the end of the day, you know, I don't know that they have a protocol that ensures that they capture everything but what they've captured. They're presenting their their results on. So they had 468 total patients with the Montasia fracture dislocation. Of these, 32 were identified as having at least one or more than one concomitant ipsilateral upper extremity fracture.
And they basically then give you their clinical retrospectives about how they manage these, you know, comparing their management strategies, reviewing the literature and you know, I guess 32 patients is a relatively large series at 7% of all the acute montagia fracture dislocations that they saw.
Not unexpectedly, those with concomitant fractures more frequently underwent formal operative intervention at close to 80% versus 50%.
Ulnar fracture fixation was also significantly different compared with those with isolated montasia fracture dislocations.
In their cohort, the most frequently involved associated fractures were distal radius supracondylar region of the humerus.
It's a Level 4 study, appropriately graded as such. This is definitely in the size of Soze moniker. I see this as just like it has so many while based on, you know what is really very limited evidence, this is like total test fodder. All sorts of questions coming out from this. I think in the future, the percentage of acute pediatric montagia fracture dislocations associated with ipsilateral upper extremity fractures, you know, which is the distal radius is the most frequently involved or what are two of the most common, including the supracontal region of the humerus.
You know, their main message is like, I thought was a little bit unusual because they say given the 7% incidence, surgeons should maintain a high index of suspicion. Well, I mean, I think you have to have a high, you know, for things that have less than a 1% incidence, like cauda equina syndrome, we still maintain a high level of vigilance.
[00:06:04] Speaker B: Right.
[00:06:04] Speaker A: Like so across the board. These are, you know, the most common reason that you miss a fracture is body part not imaged.
So these are relatively, are a higher, higher energy mechanisms or transfer of higher energy forces when a patient presents with something like this. So I think, you know, a more extensive workup is certainly warranted.
I don't know what else you can really take from this.
I don't think it's necessarily translatable to other centers. Again, it's just one center's experience. Other centers may do things differently. We need the Boston Children's experience or the Texas Scottish Rite experience.
[00:06:48] Speaker B: That's all coming next, I'd say, you know, but I do appreciate 13 years of follow up. It's hard to follow up with these, you know, kids. And for this team time frame, that's what I got. All right, perfect there. All right, so I'm going to talk about oral corticosteroids, reduced pain after total knee arthroplasty. A higher dose of dexamethasone effectively controlled pain during motion. A dose response randomized placebo controlled trial by keteninate. There's a commentary and infographic and it's also free for 30 days.
This is a study out of Thailand. They are really liking their steroids.
So we are going to talk about steroids this time. And we just talked about steroids in the last episode. So historically I've personally used IV steroids in surgery and there's multiple studies also looking at oral dexamethasone, typically at 10 milligrams for two days after surgery. It does help with postoperative pain and postoperative nausea and vomiting and total knee arthroplasty. In this study from Thailand, they investigated the efficacy and dose response relationship of oral dexamethasone in pain control after total knee arthroplasty. The authors conducted a double blind randomized controlled trial comparing efficacy of 16mg and 8mg of oral dexamethasone with placebo for pain control following primary total knee arthroplasty. Patients are allocated in these three groups in a one to one to one ratio from January 2020 to March 2023 patients who are undergoing unilateral TKA for osteoarthritis and age of 50 to 85, asa classification of 1 to 3 and ability to perform informed consent were included. Patients were excluded if their hemoglobin A1C was greater than 7, BMI greater than 40, had inflammatory joint disease, used systemic corticosteroids within six months, had a history of peptic ulcer, hemorrhage, cognitive or psychiatric impairment affecting pain assessment, severe renal dysfunction or hepatic dysfunction, prior opioid use and allergy to any of the study medications.
So it's a prospective randomized trial and they gave dexamosis and placebo. They gave it on the day of surgery and for the morning of the first four postoperative days. All of them were all in the morning there. They wanted everything to look the same. So everyone got four tablets either four tablets of four milligrams of dexamethasone, two tablets of placebo with four milligrams of dexamenthasone or four placebo tablets.
The primary outcome was pain intensity at rest and during motion with a knee flexion of greater than 45 degrees assessed using 800 millimeter visual analog scale with 0 saying no pain and 100 indicating extreme pain. Secondary outcomes were the rate of post operative nausea and vomiting, opioid consumption, fasting blood sugar, serum C reactive protein, functional outcomes and wound complications.
Postoperative nausea and vomiting was none modern mild if you didn't need antiemetic or severe when you did need antiemetics and fasting. Blood sugar was most measured preoperatively on Post Ops Day 1 and 2 and CRP was measured post operative 1, 2 and 14.
Functional outcomes were passive knee, range of motion, Wool Mac, forgotten joint score and range of motion were looked at 24 hours and 48 hours, two and six weeks and three months and the similar parameters were done for for the Proms but really starting at the two and six week and three month follow up. So everything went up to three month follow up, no longer than that but three month follow up. And they use linear mixed effects modelings to compare outcomes between groups. So there are 120 patients, 40 in each group, mean age of 68 and 86% of them were female. So the patient who got 16 milligrams of dexamethasone has significantly lower VAS pain scores during the first 48 hours postoperatively both at rest and during Motion compared to the placebo group.
Pain levels in the groups converge by Post OP Day 3, so no really big difference. Now the difference here is most of our patients are home by post OP Day 3. In this scenario, all the patients were still in the hospital on post op day three and could be assessed at 48 hours. The Dec16 group had approximately 50% lower pain at rest and during motion compared to placebo group. The Dex8 group had significantly lower pain scores in the placebo group, but only at rest.
The rates of posthoba nausea vomiting were similar between groups although the DEC 16 group had a trend towards reduced opioid consumption, but it wasn't significant.
The DEC16 group had approximately 12% higher mean fasting blood sugar. As we know, corticosteroids do increase your glucose in the early post operative period compared to placebo, but the CRP levels are approximately threefold lower in the Dec16 group than in the placebo group. Functional outcomes including passive range of motion and the modified Womack and fibroids gotten joint score were similar among all groups at each follow up. And there were no superficial wound complication observed. Two patients in the three months after surgery developed a periprosthetic joint infection, one in the Dex16 group and then one in the placebo group.
So as a conclusion, the author stated that oral dexamethasone was effective at reducing pain after total knee arthroplasty, especially at the higher dose. The 16 milligram dose having superior pain relief during motion compared to compared to the 8 milligram dose within the first 48 hours.
They say that should be part of a multimodal pain regimen, especially patients who are being discharged the same day after surgery. So they can have decreased pain but no real difference in the other areas such as nausea, vomiting or wound complications. There's only three month follow up. I think a longer infection follow up is something that I'd always be careful about because you always wanna be careful with corticosteroids. They are not benign drugs. They're helpful, but they're not benign drugs.
But I do like that prospective randomized controlled trial. These are hard to do and I do appreciate the placebo pills that they had. So everyone took four pills, not just the placebo patients, but they also had that for the patients who got a lower dosage. So show some of a dose dependent effect here.
[00:12:38] Speaker A: Yeah, I thought it was well done from a randomized trial standpoint.
I think you covered all the high points. Wondering what Aisha thinks?
[00:12:46] Speaker C: Yeah, no, I'm a Huge proponent of non opioid analgesia in total joint arthroplasty. And I'm really glad the author's conduct at the study, you know, you mentioned it was done in Asia and it would be really tough to do that here because they kept the patients in for three days to measure their CRP and their fasting blood glucose. So it gave some really important parameters. We wouldn't be able to keep people in that long just to measure those things.
One of the pitfalls, they didn't power the study for one of the most clinically relevant outcomes, you know, for me, which is opioid use, that would have been a benefit. And I thought it was interesting in their clinical pathway, they included for all patients in both, both arms, all three arms to have tramadol as well as pregabalin and nortriptyline. So you. I try to stay away from a lot of these sedating medications. So I thought it was interesting that they included that as well as an nsaid. You know, they kind of concluded at the end that steroids would be a good alternative to NSAIDs for patients that can't take them. But not necessarily true based on this data since all their patients were on NSAIDs. But in the end, I think it's a really good take home message that it's something that we can add to our armamentarium for post total knee arthroplasty analgesia.
[00:13:46] Speaker B: Excellent. All right. They did have regimens that people did follow very carefully, which I don't think we all definitely do the same multimodal approach. You're exactly right.
All right, so Dr. Abbey, now please tell us about antioxidant loaded highly crosslink polyethylene may reduce revision risk in totaling arthoplasty. A US based cohort study by Prentice et al. And there's also a commentary on this.
[00:14:08] Speaker C: Great. Yeah, this is a really important topic. This study was a database study from the Kaiser Permanente Health System total Joint Registry. It's a very robust registry that, you know, conducts surveillance on all total joint replacements performed in the system for more than 90% completion of data on all cases. So it's pretty impressive, the completion of data sets that they have. They sought to compare revision rates of total knee arthroplasties that were performed with highly cross linked polyethylene bearings, both with and without antioxidant treatment of the polyethylene. So antioxidant treatment of the poly became really popularized in total hip arthroplasty as a mechanism of quenching free radicals generated from the cross linking process used to generate the highly cross linked polyethylene and make it more durable and resistant and it improves the durability of polyethylene and total hip by way of reducing oxidization of the free radicals. However, the wear mechanics in total knee arthroplasty are very different from that of the hip and it kind of remains controversial as to whether or not highly cross linked polyethylene and antioxidant treatments superior to, you know, conventional polyethylene in the knee and whether adding antioxidants to highly cross linked polyethylene is even better than highly cross linked polyethylene alone.
But despite that, but despite not knowing whether it's better, we actually have widespread use of antioxidant polyethylene and total nearthroplasty. As of 2022 in the US more than 80% of total knee arthroplasties are performed with antioxidant poly despite evidence that it's a benefit in the timeframe for this study was 2001 to 2023 and for consistency they included only cases with cobalt prone alloy femoral components and fixed bearing inserts and the patella was resurfaced in all cases.
All implants were from one of two manufacturers, either Depew or Zimmer Biomet and for one of the two manufacturers there was an implant that had increased loosening for the first generation of its fixed bearing TBL component and they excluded that completely from their analysis. The study included a whopping 48,000 cases or more of total nerythoplasty in the antioxidant group and 44,000 in the group without antioxidants and outcome measures were revisions for specific reasons including septic aseptic revisions and specifically aseptic revision for wear and loosening and the data was complete for 92.3% of the cohort and the covariates included age, body mass index, gender, race, ASA class, bilateral procedures, fixation type and implant constraint. Whether it was a cr, PS or ultra congruence, the surgeon annual volume as well as the OR time.
Since the process of adding antioxidant differs between manufacturers, a secondary manufacturer stratified analysis was performed.
The authors found that at 13 year revision rate was 3.4% with the highly cross linked polyethylene group with antioxidant and 4.2% for those without antioxidant. So not a huge difference and after adjustment for all co founders confounders there was a lower all cause revision risk and aseptic revision risk in the antioxidant group and a lower risk for revision for wear. There were very slight differences for the manufacturers, so in the DEPEW implants there was a trend toward reduced all cause revision but no statistical significance, whereas there was a lower risk for revision for loosening in the antioxidant group and in the Zimmer biomet group. There was a significantly reduced risk for all cause revision in the antioxidant group and a lower risk for wear in this group compared to non antioxidants.
The strengths of this paper are it's a very robust data source. The Kaiser Permanente database collects predefined information for more than 454 community based surgeons in eight geographic regions.
However, the observational design of the study lends itself to some limitations. The study encompasses a very, very broad timeframe of 22 years from 2001 up to 2023 and over that course in the timeframe starting with antioxidant poly became available only in 2008. The use of antioxidant use in their cohort went from 0% to 90% over the subsequent years.
The study doesn't account for all the changes in practice that have evolved over time, including the use of robotics and enhanced recovery protocols. In particular the use of txa, which has an indirect effect on revisions for infections and patient optimization that has changed considerably over those two decades may also affect revision rates as well.
Less of time has elapsed since the antioxidant infused poly cases were done in comparison to the non antioxidant cases and therefore there's this temporal bias that can affect revision risk as well.
In the author's discussion they include data that's been published on this subject comparing conventional polyethylene to the antioxidant polyethylene. Again, there was no difference.
Other studies comparing highly cross linked polyethylene and conventional poly and total neuroarthroplasty don't show compelling differences in survival or even patient reported outcomes and other findings. And so perhaps in the end we just need conventional poly, but the reality is that we probably won't go back to conventional poly just despite its lower costs and its equivalent outcomes in comparison to highly cross linked poly in the knee, primarily because conventional poly got such a bad rap in the total hip replacement space. And also maybe in this wellness obsessed world we live in, antioxidants have become such a bulk buzzword purported to solve all our problems. You know, anti inflammation to heart disease to cancer, not to mention anti aging properties, antioxidants can do no wrong. So why not add it to our total knees, Right? But in all seriousness, I think the study demonstrated revision rates are very low regardless of using highly cross linked polys with or without antioxidants. And the risk of revision is lower with antioxidant by less than a percent.
So while it's a well conducted study with robust data due to the confounding factors inherent to the antioxidant group having undergone surgery so much more recently than the control group by more than a decade, during which time so many factors have contributed to improved outcomes in total knee arthroplasty, I think we can only state a correlation and not a causation here of antioxidant polys and improved implant survival. And so I would say our case is for antioxidant highly cross linked polyethylene until near placement remains on hold.
[00:20:15] Speaker B: This does not substantiate the use of them 100%. You're exactly right.
So it is one of those things where I appreciate the insight that you put here. I agree it's an on hold product. It's one of those things where unless you show that quenching the free radicals leads to exactly the increased survivorship or increased outcomes and we don't have the fluid data to show that or exactly what those reasonings are for. So until then it is truly correlation and there's not causation in that aspect of things.
All right, moving along to our next one. The prevalence of subtal arthritis following P line fractures by Joshi et al. There's a commentary, there's a visual summary, it's the lead article and it's free for 30 days. It is not the trifecta anymore, the quad facta of things that you could have here at jbjs. So Pilater fractures result in substantial morbidity and are associated with a high rate of ankle arthritis after external fixator placement and are open reduction and internal fixation. But for commutated P L fractures, a lot of times surgeons are putting in tibial talo calcaneo or TTC arthrodesis as an option, especially in elderly patients because you can perform early weight bearing through these constructs. But a counter argument against these acute hindfoot nailings that it requires violation of the subtalar joint even though the injury only involves the tibial tailor joint. Literature is scarce regarding the prevalence of post traumatic subtal arthritis after pilon fractures.
That said, even though the authors mentioned ttc, the focus of the article is entirely an open reduction internal fixation and they really didn't cover TTC arthrodesis at all.
They said the aim of this investigation was to assess the development of subtal arthritis after ORIF of an acute P line fracture using the Kelvin Lawrence system, the NSS system which is none sum severe system and the CT ankle osteoarthritis system or CTAO.
Patients who are greater than 18 years old and presenting at a Level 1 trauma center with P lung fractures between November 2000 and June 2022 were included. Patients with concurrent talar or calcaneal fractures and were treated by means other than ORIF were excluded, including the nails they mentioned. P line fractures were classified using the AO and ota class systems as 43A which is extra articular, 43B which is partial articular or 43C intraarticular on radiographs or when available CT scans. And again we already have the different systems they read there. The KL system 0 to 4. It's a well known system especially in the knee. The NSS and the CT grading systems were 0, 1 and 2 or 01, 2 and 3. There was 0 being no arthritis and 2 or 3 being severe arthritis. There were stats done with the mean differences in KL grades, Walch's T test and two cell tests.
ANOVA was used to compare mean NSS scores and they looked at four different time gradients. The group one had the least amount of time which is less than 12 months, group two was 12 to 24 months, group three was 25 to 48 months and group four was greater than 48 months with the thought process that the further you are from surgery the more likely to develop arthritis. So the studies included 473 patients, mean age of 46 with 293 male and 180 female. The cohort was comprised of 80% white and 15% non white with almost 4% of missing data.
What attributed to this arthritis or this post traumatic arthritis patient, age at the time of injury, at the time of imaging, smoking status, steroid use, Charleston Comorbidity index, AO and OTA classification and the time from injury to final imaging that was associated with KL grades. Specifically group three as a reminder was a group from 25 to 48 months was found to have a higher mean KL grade than Group 1 or Group 2. Group 4 not surprisingly had a higher KL grade than Group 1 and Group 2 and the CTAO score demonstrated meaningful correlation between subtalar arthritis and age at both the time of injury and the time of the final CT scan.
They did a chi square comparison of osteoarthritis grade distributions according to both the NSS and the KL systems and they had no significant differences between fractures with high and low energy mechanisms. They had a whole definition of high energy mechanisms, some of those that fall from a certain height, car accidents, motorcycle accidents, et cetera.
The authors concluded that multiple patient factors including age, smoking status, steroid use, Charleston Comorbidity Index, AO TA classification, those that are articular are more likely to likely lead to arthritis and time intervals since injury were significantly associated with the development of subtelor arthritis assessed using the KL grade after P line fractures. Although the NSS score also increased in a time dependent manner, these differences did not reach significance and the CTAO score also did not exhibit any significant differences between time groups, but it did show correlations of subtalar arthritis with age at the time of injury and the age of the last radiographs. It's really interesting, they showed that there are a lot of factors that are associated with post traumatic arthritis. Makes sense. But then the authors concluded this suggests that acute hindfoot nailing as an index treatment option for P line fractures may have fewer clinical ramifications than had been anticipated on the basis of its violation of the subtalar joint. I'm not quite sure where this conclusion comes from because literally they did not look at any patients who got any TTC arthrodesis. They were purely ORIF patients. In fact they excluded anyone who got anyone but orif. So I'm not quite sure that this is highlighted both in the abstract and the conclusion and throughout the discussion. So just say keep the conclusion the way it is, use your data and conclude from the data. But otherwise the data itself was interesting enough in the subtal arthritis space.
[00:26:06] Speaker A: Yeah, I agree with you wholeheartedly. That is just such a major non sequitur that it's almost out of bounds and a non sequitur out of bounds. I thought this study was interesting. It had an interesting premise. They're using relatively large number of patients and I don't have a problem with any of what they said. Short of that very like tangential conclusion that I don't think should be applied to clinical practice.
It also left me on.
It left me wanting so much more from the study if that's fair.
First off, something to point out is that the data were collected from over 20 years, 2000 to 2022. Long time and there are no controls for secular trends. In fact, their analyses really don't Control for anything they're doing. Andovas and Pearson correlation chi square.
So these are not adjusted analyses. And when you're talking about post traumatic arthritis in this context or any other, what we're really looking at here is the intersection of age, the baseline arthritis that's present, the baseline circumstances of the joint, and then the severity of injury.
And to really speak to this meaningfully, I think you have to have an analysis that covers all of those domains in a robust analytic way. And that that just isn't present here. I also do not understand this is such a heterogeneous group as you covered, with some having short follow up, others having, you know, over four years of follow up, some getting CT scans, others not. This is not level three evidence as advertised. This is, this is level four evidence. It can't be anything but their analysis don't even adjust for confounders. I mean, it's as level four as level four gets. So the level of evidence that they advertise is on hold. I think that the lack of more robust, meaningful, deep analyses to get, some of which they might not have been able to do, but I think that the study itself is relatively superficial. So I don't think that the findings necessarily can be assumed to translate to other clinical contexts. So that goes on hold. And then just like you brought up that claim about how to apply this in clinical practice on a topic that isn't even studied is 100% on hold.
Ayesha, what do you got?
[00:28:41] Speaker C: Yeah, I would agree. I mean, it's interesting because they have long term data. It's a relatively important topic in terms of finding out the outcomes of the subtalar joint. But again, that sort of dichotomy between their data and the conclusion was the issue for me. And I would also agree that it remains on hold.
[00:28:59] Speaker A: Yeah, it's just that that is a chasm that cannot be spanned with this study.
That's the beginning and the end of it.
[00:29:08] Speaker B: Lots of holds here.
Welcome to the new year, everyone. All right, finishing up with our honorable mentions. Sources of patients expectations of total knee arthroplasty by Mancuso et al. And there's a commentary on as well too. 232 patients here were surveyed and high expectations of total knee arthroplasty and derive these expectations from diverse sources spanning personal and social network experience.
Knowledge of favorable outcomes associated with better Koos junior scores. Knowledge of unfavorable outcomes was associated with more negative affect. Optimism was associated with more positive affect. And information from the Internet was associated with longer symptom duration and less negative affect. So sometimes the Internet doesn't always kill us every single time.
Lots of things to think about when it comes to patient expectations.
Thanks again for another episode. Thank you Dr. Abdeen for joining us as a guest on our podcast here. We hope you enjoyed what you heard and come back for more.
[00:30:06] Speaker A: I think it went so great. Dr. Abdin might be back on the next episode too.
[00:30:11] Speaker C: Thanks. Great guys. It was great to be here.
