OrthoEvidence

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Preventing Infection in High-Risk Total Joint Arthroplasty Published in @JArthroplasty Periprosthetic joint infection (PJI) is rare but devastating. Minimizing the risk of PJI, particularly in high-risk patients, is imperative. But what's the best protocol to do so? METHODS 1,901 total joint arthroplasty patients at high risk for PJI were randomized across 17 different sites in the USA to receive either: 1) Vancomycin powder 2) Dilute povidone iodine 3) Both vancomycin and povidone-iodine 4) Saline The primary outcomes of interest include PJI, wound complications, emergency department visits, readmissions, and serious adverse events. RESULTS 821 patients received total hip arthroplasty and 1,080 received total knee arthroplasty. There were no differences between study groups in the incidence of: - wound drainage or dehiscence - cellulitis or abscess formation - 3-month infection rates - aseptic revision rate - emergency department visits - readmissions - wound complications - PJI or other surgical outcomes BOTTOM LINE In high-risk patients, the use of prophylactic measures like vancomycin powder, povidone-iodine, or both did not result in any marked reduction on infection rate vs. saline -- particularly in circumstances where surgeons are using a range of sterile and antibiotic techniques that are now standard of care.

Haliburton Out With Achilles Injury in Game 7 Loss Two injuries are universally feared among elite athletes, regardless of the sport -- Achilles tendon ruptures and anterior cruciate ligament (ACL) ruptures. Last night, in Game 7 of the NBA Playoffs, Pacers star Tyrese Haliburton left the game early after suffering a supposed Achilles tendon rupture. This has been a major talking point this playoffs, with both Jayson Tatum & Damian Lillard suffering similar injuries. In our OE Original, Maximum Performance, Maximum Risk: ACL and Achilles Ruptures in Elite Athletes, we discuss the treatment options available for Haliburton going forward.

Citation: Bailey et al. (2020). Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. New England Journal of Medicine 382, 1093–1102.

To Operate or Not To Operate: Persistent Sciatica Published in the @NEJM Methods ➡️ 128 patients with sciatica symptoms lasting 4-12 months ➡️ Randomized to receive either microdiscectomy surgery or 6 months of conservative therapy ➡️ Primary outcome of interest: pain at 6 months follow-up Results ✅ Pain at 6 months was significantly lower in the surgery group ✅ Leg and back pain lower in the surgery group at 12 months as well ✅ Superior quality of life and function scores in surgery group ✅ Higher rate of satisfaction and higher employment rate at 12 months 🏁Takeaway For patients with persistent sciatica, surgical intervention appears to provide substantial advantages over conservative treatment!

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@jbjs Citation: Ekhtiari et al. (2020) Total Hip Arthroplasty Versus Hemiarthroplasty for Displaced Femoral Neck Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Bone and Joint Surgery 102(18):p 1638-1645.

Total Hip Arthroplasty vs. Hemiarthroplasty for Displaced Femoral Neck Fracture: An SR & MA Published in @jbjs Methods ➡️ 16 randomized trials (3,084 patients) ➡️ Total hip arthroplasty (THA) vs. hemiarthroplasty ➡️ Outcomes including revision, function, quality of life, mortality, dislocation, peri-prosthetic fracture, and operative time ➡️ Meta-analyses performed Results ✅ Small advantage in quality of life for the total hip arthroplasty group (below minimum important difference) ✅ No difference in the rate of revision up to 5 years follow-up ✅ No difference in function up to 3 years follow-up ✅ No difference in rate of dislocation or peri-prosthetic fracture ✅ 22 mins shorter operative time in the hemiarthroplasty group Takeaway 🏁 THA and HA provide similar clinical outcomes -- THA might provide a small benefit in quality of life, while HA is slightly faster to perform!

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Citation: Hermans, Sem M M et al. “A Randomized Controlled Trial Using Epidural Analgesia for Pain Relief After Lumbar Interlaminar Decompressive Spine Surgery: The RAPID trial.” Spine vol. 49,7 (2024): 456-462.

Epidural Analgesia After Lumbar Decompression Surgery Published in #Spine Journal Research Question In patients undergoing lumbar decompression surgery, does an epidural injection of 0.25% bupivacaine significantly reduce post-operative pain severity compared to placebo? Results Pain Severity Pain scores in the 48 hours post-operation were significantly lower in the epidural group compared to the placebo group, particularly in the immediate post-operative period (first 8 hours). Opioid Use, Quality of Life, and Recovery No difference in opioid use, quality of life, or recovery scores were observed between the two groups. Complications Two complications were reported, both in the control group. No differences in the rate of complications were observed between the two groups. Takeaway An epidural injection with 5mL of 0.25% bupivacaine after lumbar decompression surgery significantly reduced immediate post-operative pain scores, with no increase in opioid consumption!

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Citation: Rossi, Luciano Andres et al. “Leukocyte-Poor Platelet-Rich Plasma as an Adjuvant to Arthroscopic Rotator Cuff Repair Reduces the Retear Rate But Does Not Improve Functional Outcomes: A Double-Blind Randomized Controlled Trial.” The American journal of sports medicine vol. 52,6 (2024): 1403-1410.

Adjuvant PRP in Arthroscopic Rotator Cuff Repair: A Double-Blind RCT Published in AJSM @aossmjournals Research Question Does adjuvant leukocyte-poor PRP injection, applied after arthroscopic rotator cuff repair, decrease the risk of re-tear in patients with rotator cuff tears, up to 1 year post-op? Results Retear Rate The rate of re-tear was substantially lower in the patients who received PRP injection compared to the control group (15.2% vs. 34.1%, p=0.037). Patient Improvement Patients who received PRP injection reported higher improvement scores compared to those who received surgery only at both 6 and 12 months (p<0.05 for both). Patient Reported Outcomes Pain, function, and sleep quality were similar between the two groups up to 12 months post-operation. Takeaway Leukocyte-poor PRP as an adjuvant to arthroscopic rotator cuff repair significantly reduced the risk of re-tear and improved the patient's perception of improvement!

Read the full OE Original here: myorthoevidence.com/Blog/Show/231

Citation: S Mahmoud, R Rambani, OrthoEvidence. Current concepts of treatment of Femoroacetabular Impingement Syndrome.. OE Original. 2024;8(7):1.

Current Treatments for Femoroacetabular Impingement Syndrome An OE Original We looked at the recent literature comparing hip arthroscopy and physical therapy for the treatment of FAI. Non-Operative Treatment Physical therapy programs, particularly active and supervised types, have demonstrated effectiveness in improving function. There is also evidence suggesting that injection therapies, like HA or corticosteroids, can provide some symptomatic relief. Surgical Intervention Hip arthroscopy has emerged as the best available surgical intervention for FAI, providing superior clinical outcomes compared to open surgery. Advantages include: - less invasive - shorter hospitalization - faster rehab - ability for bilateral performance - better survivorship However, nerve palsy-related complications have been reported. Physical Therapy vs. Hip Arthroscopy We ran a meta-analysis of RCTs that compared quality of life scores between the two treatments: Quality of Life at 6 Months No significant difference between groups, but trending in favour of hip arthroscopy (p=0.15). Quality of Life at 12 Months Significantly better in the hip arthroscopy group (p<0.001). Range of Motion The FAIT trial (Palmer, 2019) found that hip arthroscopy led to significantly better hip flexion range of motion. A previous systematic review also came to similar conclusions (Diamond, 2015) Takeaway FAI can be effectively managed with hip arthroscopy, with superior quality of life and functional outcomes being observed compared to non-operative treatment based on the existing literature!

Citation: Kaiser, Radek et al. “Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials.” Journal of neurology, neurosurgery, and psychiatry vol. 94,8 (2023): 657-666.

Decompression With or Without Fusion for Degenerative Spondylolisthesis: A Meta-Analysis Published in @JNNP_BMJ Research Question In patients with degenerative spondylolisthesis, how does decompression with spinal fusion compare to decompression alone with respect to clinical outcomes? Results Disability: no difference in pooled Oswestry Disability Index (ODI) scores was observed between the two groups (p=0.75). Back Pain: patients who received decompression without fusion were associated with a lower severity of back pain (p=0.02). Leg Pain: no difference in pooled leg pain scores was observed between the two groups (p=0.65). Peri-Operative Outcomes: decompression without fusion was associated with a shorter operative time, lower blood loss, and shorter length of stay compared to decompression with fusion! Takeaway The current evidence suggests that spinal fusion is not necessary, and may actually have significant disadvantages compared to decompression alone for patients with degenerative spondylolisthesis!

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Citation: Xiao, YP., Xu, HJ., Liao, W. et al. Clinical application of instant 3D printed cast versus polymer orthosis in the treatment of Colles fracture: a randomized controlled trial. BMC Musculoskelet Disord 25, 104 (2024).

3D-Printed Cast vs. Polymer Orthosis for Colles Fractures Published in @BioMedCentral MSK Research Question In patients with Colles fractures, how does a 3D-printed cast compare to a polymer orthosis with respect to wrist pain, function, satisfaction, and radiological outcomes? Results Pain: pain scores at 2 weeks were significantly lower in the 3D printed cast group (p=0.033) Immobilization: the effectiveness of immobilization and satisfaction with immobilization after 6 weeks were both in favour of the 3D printed cast group (p<0.05 for both). Function: measured with the DASH scale, wrist function was significantly better in the 3D printed cast group at both 2 and 6 weeks post-fracture (p<0.05 for both). Radiological: palmar and ulnar inclination angles were significantly greater in the 3D printed cast group at both 2 and 12 weeks (p<0.05 for all). Takeaway Patients with Colles fractures who received a 3D printed cast reported significantly better clinical outcomes and higher satisfaction compared to those who received a polymer orthosis!