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.
Welcome back, everyone, to your Cases on hold, episode 95.
This is December 2nd for the December 3rd issue. If you're listening, on the day we drop, we are covering the best in orthopedic research and everything that there is in the issue of JBJS this month.
I am Andrew Schoenfeld, Associate Editor for Methods, and I have with me here.
[00:00:56] Speaker B: Antonia Chen, Executive Editor at jbjs.
[00:01:00] Speaker A: As always, our opinions are our own and not reflective of the editorial board or the constituent editors or the Editor in Chief or the board of trustees or GBGS Incorporated. It is. The holiday season is upon us again, which is wonderful. And if you're looking for gifts for the orthopedic person in your life, or maybe a researcher, give the gift of subscription to jbjs. JBJS CME Miller Review Course. We got the whole JBGS bundle in terms of bringing you this this episode of your Cases on hold. Hopefully everyone is getting into the spirit of the season as we come on the New year. As I mentioned, this is episode 95. We are now on the final approach to episode 100, just five episodes away, really. So looking forward to that milestone. And as we've already mentioned, there are changes afoot. Changes in the editorial board at JBGs, changes in the look of JBJs, changes in the content and the features of JB JS. And there'll be some changes in to your cases on hold as well in parallel. But you have to. That's just a teaser. You're going to have to stay tuned for that in the next couple of episodes.
So, did I miss anything?
[00:02:24] Speaker B: That's pretty good. I like the subscription idea. And if you want to do some learning, there's some good online places you can get your SAEs and your CMEs and everything through JBJS. So lots of good learning there. Great gift, especially when you have downtime.
[00:02:38] Speaker A: One stop shopping. That's all there is. You know, get. Get situated by the fire.
Nice and cozy, right? Like I'm painting that ambiance. You got your j. J.S. on the computer imprint. Whatever it is, you're good to go.
Let's get into this issue. The top of the pile we have sacral insufficiency, fractures, pathology, management and outcomes by Collins and colleagues. We have Orthopedic Resident Dismissal, a Sentinel Event by Oday.
Then we have Appreciating the Role of Narrative Medicine in Orthopedic Surgery by Glenn and this is Permanently Free How Being a Patient Led to Surgical Insights by Zhang. Permanently Free and this is a highlight for the COVID With the new cover, which you may have seen in the last issue, there are particular articles that are featured and highlighted on the COVID A lead and two highlights. So this is one of them. Then we have Bayesian Thinking and Principles, Practice and Pitfalls by one of the associate editors for methods, Dr. O'. Hara we're revisiting surgery for Proximal Humeral Fractures. How much high quality evidence is needed to de implement surgery introduced without high quality evidence? That's a real riddle. This is by Brorson.
Then A Medical Student's Reflections on Autism, Movement and Orthopedic Collaboration beyond the Clinic by Visioso.
What's New in Musculoskeletal Tumor Surgery by Gazandam with a highlight and this is Permanently free.
Then that brings us to the headlines. What's new in the Orthopedic surgery news this week? My headline is Hurricane Blade versus Lag Screw Fixation in the Cephalomedullary Nailing of Geriatric Hip Fractures by Okike and Colleagues with an infographic 30 days free and you don't have to take it from me. It also comes with a comment.
This study is done by a group that does a lot of research through the Kaiser Permanente Registry. Full Disclosure There are several authors on this paper that are members of the editorial board at JBJS. The first author, Dr. Oke, who I believe is an associate editor for Trauma and Healthcare Disparities.
And then I think Dr. Navarro also has associations with JBGs as well, but we won't go light on them anyway.
So this study leverages the Kaiser Permanente Registry. It's a retrospective cohort study looking at hip fractures to identify patients over 60 who underwent cephalomedullary nailing with a helical blade or lag screw from 2009 to 2023.
And then they use propensity score weighted Cox proportional hazards regression to evaluate the risk of aseptic revision, which is their primary outcome, and then the risk of revision for specific reasons, which was the secondary specification. And mortality was considered a competing risk, which is definitely a best practice.
The study included over 22,000 cases and again, they're using propensity score weighting, so this isn't truncating the Sample, they have close to 11,900 with the helical blade and 10,400 with the lag screw.
Ten year cumulative incidence of aseptic revision was just about 1.7% in the helical blade group and 1.9% in the lag screw group. And then the helical blade outperformed the lag screw in one subgroup which was patients with an ASA of 1 to 2, but not in those with ASA scores of greater than 3. And the difference in the 1 to 2 group was 1.7 versus 2.6, so a 0.9 percentage point difference across the board. Of course, given that sample size, they estimate it's a 35% hazard reduction with a confidence interval, the upper bound of which was 0.98 and a P value of 0.04.
And then the aseptic revision incidence for Those greater than 3 was 1.72 versus 1.64. And that was not significant because of overlapping confidence intervals and a very low point estimate for the hazard that approximates one in any case.
So the motivational premise here is that, and this is just reading from what the authors say in the introduction. In prior research, helical blade fixation has been associated with biorates of fixation failure, cutout cut through and medial migration in comparison to lag screw. But then there are other reports, of which they cite four that have shown the helical blade fixation performs similar or better. Two articles substantiating that to lag screw fixation.
So they want to weigh in on this with their registry, which is, which is fine in these types of studies where you have some four and some against and some showing no difference.
It tends to highly depend on the sample size, the surveillance period, the event rates and confounding. By indication.
We have said before, and I think this really stands here, that equivalence of outcomes does not necessarily mean equivalence of treatment. If you have like two separate populations for which there are two different procedures, and the two different procedures perform equally well in those populations, it doesn't mean that if you did the same procedure across populations, you'd have the comparable results.
The idea, of course, is that the right patient gets the right treatment to get them to the same point, which is successful recovery from the fracture and no impact on survival or as limited an impact on survival as possible in the time window subsequently.
So that's sometimes why you get these sort of discrepant reports in the literature. And their goal here was to use the causal inference technique because of course there may be confounding by indication.
So they want to balance the groups prior to the outcome assessment and they use propensity score weighting. And they said that they employed a multivariable logistic regression with relevant covariates as predictors of the treatment assignment. And that's all well and good, but there's not a lot of clarity around what all they included in there. And that's probably one of the few false notes in what otherwise is a pretty well done study.
Now, ultimately, at the end of the day, they found really negligible differences. And I would argue that a 1 less than 1 percentage point difference even in the ASA 1 to 2 group, you know, they, they maintain that that warrants, you know, it's an interesting finding and warrants further research. I'm not, I'm not sure it does. I think that's just kind of normal. A 1 less than 1 percentage point difference between two populations. The significance just has to do with the size of the sample. I think everything about this particular study really says that there's an equivalence of treatment between the two designs.
Now, some people may have a preference, one versus the other in terms of their, their skill in applying the technique. And I certainly, whether it's a patient with a low ASA or high assay, I wouldn't change practice based on this. If you're using the lag screw or you're using the helical blade, whatever you're comfortable with, you should probably just stick with it.
[00:10:42] Speaker B: I think that's true for most surgical approaches. Right. Or surgical techniques. If you haven't had no experience with it, you probably shouldn't be using it. That's what I think. We go with it. But it is a well done study. I agree. The three different arms are also very useful. It does say for healthier patients, maybe you want to do something like a helical blade, but just be sure that you've done it in practice before you experiment on someone.
[00:11:03] Speaker A: Yeah. And again, the return on it is very.
[00:11:07] Speaker B: Not a huge difference.
[00:11:07] Speaker A: Right?
Not a huge difference in. I mean, they're estimating a 35% reduction in the hazard ratio, but when you look at the event rates, it's an uncommon event. Any way you slice it.
[00:11:21] Speaker B: Exactly.
[00:11:22] Speaker A: All right, so next we have your headline. Posterior cruciate ligament versus combined PCL and posterolateral corner reconstruction in isolated PCL grade 3 injuries by Yoon and colleagues with a comment and visual summary.
[00:11:39] Speaker B: So this study here was looking at isolated PCL injuries which, you know, does or does not happen. It's a grade three injury. So what is that? Those are PCL injuries without any other ligamentous pathology that have a posterior translation greater than or equal to 12 millimeters compared to the contralateral knee. So the study asked what are the best ways to fix these injuries.
So this study looked at two different surgical methods. Basically it's PCL reconstruction alone and then PCL reconstruction plus posterior lateral corner reconstructure or PLC, not to be confused with PCL. So PLC plus PCL and versus PCL alone reconstruction. These are patients who had injured between 2008 and 2020. They were retrospectively reviewed. They looked at posterior translation by a stress radiography called telos with the 5 newton meter posterior torque on it and posterior instability was measured in 90 degrees of flexion. They used the IKDC subjective score, the Lysolm knee score and the Tegner activity scale both preoperatively and each follow up. They defined failure as failure of PCL reconstruction for they define failure as needing additional surgery due to unresolved symptoms. Complete graph failure shown by MRI scans and or grade three instability on stress radiographs, basically being above 10 millimeters.
Of the 448 patients with the PCL injury, 254 of them had an isolated PCL injury and they were identified.
Six of these had a grade three posterior translation. So 30 patients were excluded due to lack of follow up. So at the end of the day they only had 30 patients. That's not a huge number of patients that they were comparing against.
Of the 4, 448 that they started with and the 254 an isolated PCL injury. Eight of the injuries were sports injuries, nine were motor vehicle and 13 were injuries during daily activities. 25 were contact injuries and five were non contact injuries. So in group one they also had meniscal tears identified.
Group one was the isolated PCL reconstruction. There were 17 patients who underwent just PCL reconstruction and 13 patients who underwent both PCL and PLC reconstruction. In group two they did have concomitant findings as well too. They had four with meniscal tears. In group one, some had three had outer bridge one or two cartilage lesions. In group two there were five meniscal tears and three were treated with partial meniscectomy and there was one grade three cartilage lesion tear.
So at the end of the day in groups 1 and 2, posterior translation compared with the contralateral improved from Greater from approximately 13.7 and 14.6 to 3.2 and 7.1. So in Group 1, they went from over 12, which was around 14, and they went to 3.2. So Group 1 was much tighter after surgery. And Group 2, which had the PCL and PLC reconstruction, they run 14, 14.6 to down to 7. So a little bit higher in the Group 2 in terms of the laxity afterwards.
In Group 1, the mean PROM score of IKDC, Leish, Helm and Tegner scores went from 55 to 57 approximately and from 4 to 5.5. In Group 2, the improvements were higher in magnitude but to similar levels at the end. So in group 2, with who needed the PCL and PLC group, we started lower at 47, but got up to almost 70 and then from 5.2 to 7.7, 77.8, which is very similar, similar to the group 1, and then 4 to 5.2, which is similar to group 1. There were no differences observed between the groups.
So ultimately what it comes down to is patients who have an isolated PCL injury, grade three injury, who underwent isolated PCL reconstruction has significant improvements in objective outcomes, but there are really no differences between those who underwent isolated PCL and those who underwent PCL and PLC reconstructions, is what the authors state.
The hardest part for me is the bias with this study who underwent a PCL alone and who underwent a PCL + PLC.
This is a retrospective study. These weren't randomized. Every surgeon had a reason for doing so. Doesn't say that the person did both PLC and PCL surgeries. It might be that patients only got a PCL reconstruction if they only felt comfortable with the pcl. Could it be that there was more dissection for doing the PLC or the posterior lateral corner reconstruction? Were the patients worse at baseline? There was some indication that they had slightly lower proms with regards to IKDC scores, and then so they got better over time. But did it really make a difference? Or were they, you know, a different population of patients who got the combination of procedures? So do note that while they're not significantly different, the patients who had both the PCL reconstruction and the PLC or posterior corner reconstruction had more laxity after surgery than those who just got the PCL alone.
Love to hear your thoughts on this.
[00:16:41] Speaker A: Look, it's really.
It can't be anything more than a standard rote clinical retrospective of the author's experience with these procedures. And while I understand, you know, the injury itself is rare and there may not be, you know, high quality data in the context of this particular research area, research approach, the fact of the matter remains that they had 60 patients with the grade 3 posterior translation and only half of them are able to be included here.
I know you touched on that already, but I think that's pretty profound. And this is collected over the course of 2008 to 2020.
You already mentioned the expertise bias and then also the potential of confounding by selection and indication. I think they just have a restricted event rate and the limited sample they can't really speak to.
I think they're underpowered to really speak to what differences may be relevant.
So they're underpowered overall for comparisons and then they are also light. With just 30 patients, just by chance you're not going to have that many complications or something like that unless it's a type of procedure that lends itself to very high complication rate.
So it's restricted clinical variation and inadequate representation to speak to what is the likely profile in terms of complications. So. So they're not only underpowered in terms of comparison but but also unlikely to detect relatively rare adverse events or outcomes. I cannot reconcile this level three evidence. This is really as level four as level four can get. I understand that there's this putative comparison that they're making, but it really is a rote clinical retrospective and when you factor in the limited sample, the restricted event rate, restricted clinical variation, I don't see that this is nothing more than here's the author's experience with these cases over the 12 year time window and I don't think it necessarily can be used to inform or direct clinical care practice, certainly in other contexts.
[00:18:56] Speaker B: Agreed.
[00:18:57] Speaker A: Now we're into the your case is on hold featurette.
Debridement of unstable chondral lesions during arthroscopic partial meniscectomy provides no long term benefit Patient outcomes nine years after the original CHAMP trial. This is by Bisson and colleagues with an infographic, a comment 30 days free and it's the lead article for this issue. So naturally we would include it for our very robust head to head discussion and erudite insights into the advantages and disadvantages of this particular work. So this, as they said, it's a nine year surveillance on a previous study. The study was the Chondral lesions and meniscus procedures trial which had previously found no benefit to debriding chondral lesions during APM at one and five year follow up intervals. So now they want to look at the patients at nine years after surgery. It's not clear but typically in these situations when you get this very long term follow up, it's not a scheduled follow up time point. It's just the authors leveraging the connections they've made with these patients that they've randomized in a trial, meaning that the power calculations and the primary assessments that went into the actual randomized. This is not a specified outcome time point. And oftentimes you see a fair amount of patients are lost to follow up. And randomized controlled trials don't usually have that large volume of patients to account or adjust for that. That is the case here as well, although the numbers are fairly reasonable. Of the 190 patients in the original trial, 140 of those in the observation group and 76 of those in the debridement group, I think that they had 190 patients original. They got 140 to participate at nine years, 64 in the observation and 76 in the debridement group. They were available for outcome collection.
And of those patients, 25 or 18% had subsequent surgery on the index knee.
You start with the idea that you have this waterfall of patients and just through the voltage drops you get to the point where it's really just a few dozen. For their purposes, there were no significant differences between the groups with respect to the Womack pain score. Other problems, physical assessment measurements, radiographic measurements of joint space narrowing and the surgically treated knees are rates of subsequent surgery. And their conclusion is that the findings indicate there was no benefit to debriding unstable chondral lesions at the time of arthroscopic partial meniscectomy, otherwise referred to as APM in the study.
So the first thing that I would say, well before, before we get into what I would say, let's see what they advertise in terms of the strengths. So they say the strengths of their study include prospective randomized trial, which I would push back on because this is not the prospective. You already published the prospective trial. So you don't get to like just keep, you know, leveraging that into perpetuity.
So this is not a prospective randomized trial. To be clear, this is the long term follow up of patients who had participated in a randomized trial. And then they say their strengths are the prospective randomized trial and a novel research question.
A novel research question is not a study strength. It's just sort of its own thing. Like you can have a novel research question that no one has thought of before and do a randomized trial of two patients. It doesn't mean that that's going to be, that that translates to high quality research.
[00:22:51] Speaker B: Life changing.
[00:22:52] Speaker A: Yeah. So then they say we collected subjective outcomes on 74% of patients and objective outcomes on 69%.
But while analyzing outcomes on 61% and 56% of those cohorts respectively, which is also, you know, you're getting at.
Close to. Only half of the patients with objective outcomes are being assessed. They say there's no standard definition of unstable chondral lesions, so they developed one by consensus and that's fine. 25% of patients were lost to follow up. They did a post hoc power analysis which found that their ability to detect a clinically relevant 10 point difference in the Womack pain score was 66%.
They don't qualify that further, but that's not really that good.
So again, you are seeing some of the calcs and problems with these long term follow up studies that are looking to sort of revivify or continue to follow patients over the course of many, many years after, after a surgery. And I think it begs the question, you know, when you do a surgery, depending on the surgery and depending on the life expectancy of the patient, at what point do you consider that like, you know, the benefits of that surgery are done at this point? I mean, we see it with some of the, in the spine space, the randomized trials that are comparing patients who had discectomy surgery with those who are managed nonoperatively. And the discectomy patients do better in the short term. But then like five years later, everybody's back to like, you know, the basic same point. So then it's like, well, you shouldn't do the surgery because I mean, everyone gets to the same place five years, but for like three of those five years, they were having a better quality of life. So the aging process and degenerative changes, especially when you're talking about things like knees, as the song, the mash song goes, the sort of time will pierce our skin. It doesn't hurt when it begins, but, but as it works its way on in, the pain grows stronger. So like eventually all of these things catch up with everybody, right? So can you really, is it really reasonable to expect that when you didn't see some differences at one and five years, at nine years, then you're, that's when you're going to see the difference.
Is it any surprise that we're not really seeing a difference in the outcomes here when you didn't see ones previously?
[00:25:21] Speaker B: That's why I was asking a patient, what's the definition of success, right? They're like, I can, I don't know, ski now. I can do some crazy activity. But nine years from now, if it's bad.
Oh, well, right. I got the maximum out of it that I could in a short time frame. So, you know, we always look at longevity, and I think of that more in the context of like implants. How long does it last if you put it when you cause unchondral stable lesions? When you talk about APMs like this?
Nine years. Something's going to happen differently anyway, and that's a different biology than what happened the nine years before that.
[00:25:53] Speaker A: Right. Right. It's. I guess at this point I would call this a natural history study. I do. Would not call it an extension of a randomized trial or that the randomized trial. Especially with like 20. You know, if you came with your initial randomized trial and say we had 25% loss to followup, you're gonna have a hard time justifying that.
So, you know, I think this is, this is probably the last time the CHAMP trial should be investigated. I think we can put it to rest.
[00:26:20] Speaker B: Wait, you don't. 10 year followup? I don't understand.
[00:26:22] Speaker A: No, I don't. Not 10 year, not 20 year. I think we're. We're good at this point. Like, I think this has been conclusively answered.
[00:26:32] Speaker B: Nail in the coffin. Done.
[00:26:33] Speaker A: Yes. Okay. So now onto our honorable mentions. The Latter J procedure may induce pathokinematics with posterior humeral head subluxation. An experimental dynamic radio stereometric study by Kipp and colleagues with a comment, so you don't have to take it from me. This study is looking at the Latter J procedure and evidence of its ability to restore the glenohumeral joint kinematics in positions and outside of anterior directed load. There's limited information in that regard, so they wanted to evaluate throughout external rotation following the L procedure in shoulders with 15% anterior glenoid bone loss. Eight human donor cadaver arms were examined using dynamic radio stereometry and with anterior direct loading. The Laterger procedure restored native glenohumeral joint kinematics with the largest stabilizing effect at the end range external rotation. The clinical relevance is that posterior subluxation of the humeral head during resting and non loading activities following bladder J procedure may be a concern in terms of future posterior glenoid cartilage wear. For the authors then, we have an interesting study demystifying traditional bone setting lessons from the Mibarara Rub regional hospital by said, and this is 30 days free. This study was performed on patients who were surveyed at the orthopedic outpatient clinic at Mibarara Regional Referral Hospital in Mibarara Uganda and the aim was to investigate motivations for seeking care from a traditional bone setter, types of treatments received and the attitudes toward traditional bone setting.
So certainly out of the box relative to what we typically see. In the journal Bone and Joint Surgery, they found that orthopedic pathology influences the way that individuals seek traditional bone setting and motivations for doing so. There's also a group of patients who seek bone setting for non traumatic pathologies.
They call this superstitious beliefs, but I would look at it more as traditional beliefs that are unique to that particular cultural context in society and the beliefs in its efficacy play a role in the selection of traditional bonesetters and the use of bonesetters. So patients in the non trauma cohort that consulted with traditional bonesetters were looking to engage in treatments that could reverse witchcraft or curses that had caused their ailment.
Failure of management was the reason that was cited most by the trauma and non trauma groups for discontinuing treatment with a traditional bone center. Some really interesting insights into the use of orthopedic care outside of conventional allopathic approaches and some insights into different cultural contexts in which laying of hands or manipulation can try to affect treatment, whether that be spiritual, psychological, placebo or scientific.
I just, we just got a thumbs up.
[00:30:00] Speaker B: I agree, you know, but medicine has evolved and yet medicine has stayed the same in some places. You know, I've been very fortunate to go on Operation Walk trips to different parts of the world and it is very interesting and very neat to see how I agree with you. It's traditional, not superstitious. Traditional hauten. And they work.
My mom does Chinese traditional medicine, gives it to me and sometimes better than the antibiotics or sometimes better than the other medications. So there's a context for everything.
I hate to say this but Western medicine is not the end all be all for everything and I think it's important to highlight papers like this in JBGs. So that's what my thumbs up was for because it's encouraging to see that.
[00:30:43] Speaker A: All right, we are about out of time. We'll try to do better next time. If you are not already liking and subscribing to the JBJS your Cases on hold podcast, please do so. Spread the word. Give us a five star rating if you can.
If you like what you heard, stay tuned for episode 96 in the near future. If you did it, thanks for sticking with us this long and tune in next time for Dr. Chen's takes.
Hopefully your cases are all green. Go.
And you are imbibing the holiday cheer.
But here, while we do have holiday cheer, all the cases are still on hold.
