Published 1/1/2019

Second Look—Clinical

Hip and knee

Nerve injury after hip arthroscopy—A prospective study published in the Journal of the AAOS (Nov. 1) found that the rate of nerve injury after hip arthroplasty may be higher than previously reported, but resolution rates are similar to prior studies. The study included 100 patients (mean age, 29 years; mean body mass index [BMI], 25 kg/m2) undergoing hip arthroscopy requiring traction.

Thirteen patients (13 percent) sustained a nerve injury: pudendal (n = 9), lateral femoral cutaneous (n = 2), sciatic (n = 1), and superficial peroneal (n = 1). Increased traction time, sex, and increased BMI had no significant impact on injury risk. Eight nerve injuries resolved in two weeks, and all resolved within nine months.

Pain relief after TKA—According to a meta-analysis published in The Clinical Journal of Pain (November), continuous femoral nerve block (cFNB) is the superior treatment of postoperative pain in total knee arthroplasty (TKA) patients. Researchers used Embase and PubMed to collect data from 58 studies that included 3,501 patients.

All treatments improved pain score compared to placebo in six to eight hours except for patient-controlled epidural analgesia plus femoral nerve block (FNB) and sciatic nerve block. At 24 hours, cFNB, periarticular infiltration, periarticular infiltration plus FNB, single-dose FNB, and sciatic nerve block plus FNB outperformed the control group. Only cFNB and intra-articular infiltration yielded better results than the control group for pain score 48 hours postoperatively.

Hip fracture surgery for HCV patients—In a retrospective study published in the Journal of Orthopaedic Trauma (November), researchers observed a negative correlation between noncirrhotic hepatitis C virus (HCV) infection and patients operatively treated for hip fracture. Patients were classified as having a concurrent diagnosis of noncirrhotic HCV infection (HCV+) (n = 5,377) or not having an HCV diagnosis (HCV–) (n = 4,712,159). Despite younger age and fewer medical comorbidities, the HCV+ group had longer lengths of hospital stay, higher nonroutine discharge rates, and higher rates of complications compared to HCV– patients.

Neck and shoulder

Proximal humeral locking plates for neck fractures—A retrospective study published in the Journal of Shoulder and Elbow Surgery (online) found that anatomic neck fractures (ANFs) treated with proximal humeral locking plates (PHLPs) had poorer clinical outcomes than surgical neck fractures (SNFs) treated with PHLPs.

Between May 2013 and April 2015, 31 patients with displaced four-part proximal humeral fractures consecutively treated with PHLPs were classified by ANF and SNF. Researchers assessed parameters including neck-shift angle (NSA) and sum of the screw tip-articular surface distance at three days and one year postoperatively, as well as Constant-Murley scores at three days, one year, and final follow-up.

ANF patients tended to be younger and had significantly greater mean operative duration, estimated blood loss, and bone grafting rate. Seven ANF patients and one SNF patient developed full or partial osteonecrosis of the humeral head. Eight screw cutout and/or pullout complications occurred in the ANF group; none occurred in the SNF group. NSA and screw tip-articular surface distance sum changed significantly between three days and one year postoperatively. The tested parameters presented no significant correlations.

Risk of OA in older patients with delayed ACL reconstruction—A prospective comparative study published in the journal Arthroscopy (online) found that older age and delayed time to surgery were risk factors for developing OA 16 years after ACL reconstruction. Researchers determined patient-acceptable symptom state (PASS) in the International Knee Documentation Committee, and OA development was defined as a Kellgren-Lawrence grade ≥ 2 for 147 patients (63.7 percent male; average age at time of surgery, 27.9 years). The International Knee Documentation Committee evaluation system score surpassed the PASS cutoff in half the patients. Patients with a concomitant injury at surgery and greater preoperative anteroposterior laxity were more likely to achieve PASS. At 16.4-year mean follow-up, older patients and those who waited more than a year between injury and surgery had a higher risk of developing OA.

Risk factors for subsequent joint replacement—A study published in The Journal of Bone & Joint Surgery (JBJS; online) found that patients have a high risk of contralateral joint replacement following initial joint replacement surgery but a low risk of replacement of a different joint after index total hip arthroplasty (THA), total knee arthroplasty (TKA), or total shoulder arthroplasty (TSA) for osteoarthritis (OA). Using the Healthcare Cost and Utilization State Inpatient Database of New York, researchers identified 85,616 primary THA, TKA, and TSA patients, of whom 20,223 (23.6 percent) required a subsequent replacement of the contralateral joint within five to eight years of the index procedure. Obese patients were more likely to require subsequent replacement surgery of the same joint, as were index TKA patients compared to THA patients. Within five to eight years of the index surgery, 3,197 patients (3.7 percent) underwent replacement surgery of a different joint. Risk factors included obesity and index TSA compared to THA.

ADLs in Medicare beneficiaries after TKA—A study published in JBJS (online) associated low utilization of home healthcare physical therapy (PT) with worse activities of daily living (ADL) recovery in Medicare beneficiaries following TKA. Researchers assessed Medicare beneficiaries (n = 5,967) who underwent TKA in 2012 and received home healthcare services for postoperative rehabilitation. Patients with low home healthcare PT utilization (defined as five visits or fewer) had less improvement in ADLs than patients with six to nine, 10 to 13, or 14 or more visits. Compared to patients who had five or fewer visits, six to nine visits were associated with a 25 percent greater ADL improvement, 10 to 13 visits were associated with a 40 percent greater improvement, and 14 or more visits were correlated with a 50 percent greater improvement. In adjusted analyses, patients receiving home health care from rural agencies, those with depressive symptoms, and patients with any baseline dyspnea were more likely to have lower PT utilization.

Causes of late dislocation after THA—A study published in JBJS (online) associated spinopelvic abnormalities and abnormal spinopelvic measurements with late dislocation following THA. Researchers evaluated 20 consecutive THA patients with late dislocation for a mean of 8.3 years. At follow-up, nine patients (45 percent) had anterior dislocations, and 11 (55 percent) had posterior dislocations. Eight of the nine anterior dislocation patients presented with spinopelvic abnormalities, including fixed posterior pelvic tilt when standing, increased standing femoral extension, and increased standing combined sagittal index. Among posterior dislocation patients, 10 of 11 presented with abnormal spinopelvic measurements, including decreased spinopelvic motion, increased femoral flexion, and decreased sitting combined sagittal index. Every one-degree decrease in spinopelvic motion was associated with a 0.9-degree increase in femoral motion, which led to osseous impingement and dislocation in some patients.

Meniscal repair failures—A systematic review published in The Knee (online) found that age may not impact clinical postoperative success rates following meniscal tear repair. Researchers assessed studies that reported either individual patient data that included at least one patient aged 40 years or older or summary data with all patients aged 40 years or older. Previously reported risk factors, including anterior cruciate ligament (ACL) reconstruction, tear location, and tear pattern, were used to determine failure rates. The final analysis included data on 148 patients (125 inside-out repairs and 23 all-inside repairs) from 11 studies. The overall failure rate was 10 percent (n = 15) and ranged from 0 percent to 23 percent in individual studies with more than one patient aged 40 years or older. Most tears were peripheral, either with or without avascular extension, both of which had a 9 percent overall failure rate. When tear pattern data were available, overall failure rates were 9 percent for vertical-longitudinal or bucket handle tears, and 23 percent for complex and/or horizontal tears.

Outcomes after patellofemoral ACI—A study published in The American Journal of Sports Medicine (online) found that most patellofemoral autologous chondrocyte implantation (ACI) patients reported positive postoperative occupational outcomes and significantly decreased pain. Researchers assessed 72 military service members who underwent ACI for high-grade patellofemoral chondral defects between 2006 and 2014. Most procedures (85 percent) used a second-generation patellofemoral ACI with a type I/III collagen membrane, and more than half of defects (n = 40, 55 percent) occurred only in the patella. After treatment, 78 percent of service members (n = 56) returned to their occupational specialties. Three surgical failures (4.1 percent) occurred and required subsequent knee arthroplasty (n = 2) or a revision chondral procedure (n = 1). The only significant predictor of surgical or overall failure was the use of a periosteal patch. Age younger than 30 years, female sex, and regular tobacco use were all independently associated with overall failure.

Neck and shoulder

TSAs in high altitudes and PE risk—TSAs performed at an altitude higher than 4,000 feet above sea level may pose an increased risk of postoperative pulmonary embolism (PE), according to a study published in the Journal of Orthopaedics (December). Researchers performed a retrospective review of patients who underwent primary TSA at an altitude above 4,000 feet between 2005 and 2014. They used the zip codes of the hospitals where the procedures were performed to stratify patients: high altitude (greater than 4,000 feet) and low altitude (lower than 100 feet). Patients with a history of venous thromboembolism, deep vein thrombosis, PE, and coagulation disorders were excluded. In 30- and 90-day analyses, the high altitude cohort had a significantly higher rate of PE compared to matched patients in the low altitude group.

Effect of implant position on neck fracture—According to a study published in JBJS (online), risk factors for reoperation following osteosynthesis in patients treated for femoral neck fractures were insufficient fracture reduction, varus position of the implants, and femoral head perforation. Researchers used the Danish Fracture Database to identify 1,206 consecutive surgeries for primary femoral neck fracture treated with parallel implants between December 2011 and November 2015. Pre- and postoperative radiographs measured fracture displacement, posterior tilt, the number of implants, posterior distance, calcar distance, tip-cartilage distance, and angulation of implants. In 997 cases, two implants were used; in 209 cases, three implants were used. In 157 cases, the patient required reoperation within a year; in 228 cases, the patient died within a year. Younger patients (< 70 years) were more likely than older patients to require revision surgery (18 percent versus 9.8 percent, respectively) but less likely to die (7.4 percent versus 26.3 percent, respectively). Posterior distance, calcar distance, tip-caput distance, and parallel implants had no impact on the need for reoperation.

Glenoid factors related to shoulder dislocation—Glenoid shape may be more significant than spatial position in patients older than 40 years with anterior shoulder dislocation, according to a study published in the Archives of Orthopaedic and Trauma Surgery (online). Researchers assessed MRI outcomes performed on traumatic shoulder dislocation patients (n = 61; mean age, 59 years) and compared them to 73 MRI outcomes from patients who underwent imaging for a different reason (n = 73; mean age, 57 years). In the dislocation group, mean glenoid version was –4.9 degrees (retroversion) compared to –5.4 degrees in the comparison group. Mean inclination for the shoulder injury group was 9.8 degrees (reclination) and 10.8 degrees in the control group. Mean rotator interval base, height, and rotator interval area for the traumatic shoulder injury group were 46 mm, 14 mm, and 33 mm2, respectively, compared to 41 mm, 16 mm, and 34 mm2, respectively, for the control group.


Intrathecal injection for back pain—In a study published in the European Spine Journal (online), researchers found that intrathecal injection of low-dose bupivacaine may be a viable alternative to epidural injection to treat chronic pain in the low back and lower extremities. Lumbar intrathecal injection of low-dose isobaric bupivacaine was administered to 70 outpatients with chronic pain in the low back and lower extremities with a 25-gauge pencil-point needle in doses of 0.5 mg, 1.0 mg, and 1.5 mg at one-week intervals to determine the optimal dose, which then was administered for two weeks. Outcomes were assessed over a one-year period, during which time no patients experienced serious adverse events (AEs). In 60 percent of patients, the optimal bupivacaine dose was 1.0 mg. Pain and disability were alleviated, and the optimal dose provided anesthesia below L1.

Sagittal diameter and translation impact on SCI—Facet dislocation patients with greater translation and/or a smaller canal diameter at the injury level have higher spinal cord injury (SCI) rates, according to a study published in The Spine Journal (online). Researchers collected data on demographics, neurologic exams, and radiographic findings for 97 facet dislocation patients treated at a Level I trauma center between 2004 and 2014. More than half (n = 59, 61 percent) had an SCI. American Spinal Injury Association (ASIA) Impairment Scale grade A patients had an average 8 mm of injury level canal diameter, and ASIA grade E patients averaged 12.6 mm. For translation, ASIA grade A averaged 8 mm, and ASIA grade E had a mean 4.2 mm. Patients were classified by general motor function: ASIA grade A–C and ASIA grade D–E. ASIA grade A–C patients had a mean 8.4 mm of injury level canal diameter compared to 12.3 mm for ASIA grade D–E. ASIA grade A–C and D–E averaged 7.8 mm and 4.4 mm of translation, respectively. Translation was indicative of ASIA grade A–C, whereas canal diameter predicted ASIA grade D–E.

Foot and ankle

STAR prosthesis survival rates—Use of the Scandinavian Total Ankle Replacement (STAR) prosthesis in total ankle arthroplasty (TAA) patients was associated with good survival rates in a study published in Foot & Ankle International (online). The study involved 131 patients (50 males, 81 females; mean age, 61.5 years) who underwent 138 STAR TAAs performed by a single surgeon between 1999 and 2013. Mean follow-up for patients who survived and retained both initial components throughout the study period was 8.8 years. Between preoperative assessment and final follow-up, the mean change in American Academy of Orthopaedic Foot and Ankle Surgeons Ankle-Hindfoot Scale scores was 36. Twenty-one (15.2 percent) implant failures occurred at a mean 4.9 years postoperatively. At an average 8.9 years after surgery, 10 polyethylene components in nine TAAs (6.5 percent) required replacement due to fracture. Fourteen patients died with their initial implants.

Factors associated with correction loss in hallux valgus—A study published in Foot & Ankle International (online) found that preoperative deformity and sesamoid position may indicate loss of correction in patients who undergo distal chevron osteotomy for hallux valgus. The study involved 524 patients who underwent distal chevron osteotomy for hallux valgus correction at a single institution between 2002 and 2012. Researchers evaluated weightbearing radiographs preoperatively and postoperatively, as well as at six weeks and three months. They assessed the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), joint congruity, and position of the sesamoids. Significant improvements were observed in the IMA (12.9 degrees to 4.5 degrees) and HVA (27.5 degrees to 9.1 degrees). During follow-up, mean loss of correction in HVA and IMA was 4.5 degrees and 1.9 degrees, respectively. A linear correlation with correction loss and preoperative IMA and HVA was observed, as well as a correlation between preoperative DMAA and sesamoid position.

Concurrent intercuneiform ligament injuries in athletes—A study published in Foot & Ankle International (online) assessed injuries and injury patterns associated with unstable Lisfranc injury in competitive athletes. Injuries were categorized as traditional dislocation (TRAD, first to second tarsometatarsal [TMT] ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), and proximal extension dislocation (first, second, and medial-middle cuneiform ligament tear) in 82 patients (64 males) who were injured during sport. Injury patterns were determined at time of surgery. The most common injury was TRAD (n = 40), followed by proximal extension dislocation (n = 23) and MCD (n = 17). The most common sport being played at time of injury was football (n = 48). Basketball players (n = 13) were younger than other athletes and had a faster return to sport. Wakeboard athletes (n = 5) tended to be older and were more likely to have MCD tears. MCD injuries indicated a longer time to return to sport.

Sports medicine

Exercise improves BMD in adolescents—Vigorous physical activity (VPA) is the most effective activity intensity associated with improved bone mineral density (BMD) and content in early pubertal boys, according to a study published in Bone (online). Researchers evaluated BMD and content in 180 healthy boys aged 11 to 13 years using DEXA scans of the whole body, femoral neck (FN), and lumbar spine, and they measured their physical activity for one week via an accelerometer. Vigorously intense exercise was the activity most significantly associated with bone mineral parameters, particularly at the FN. Patients whose VPA bouts lasted five minutes or longer had higher FN BMD compared to those who did not complete five minutes of VPA. Exercise duration of 15 consecutive minutes was the most beneficial. Patients with a low volume of physical activity and a VPA bout had better FN BMD than patients with a high volume of physical activity and no VPA bout. High-volume physical activity and VPA bout patients had the best FN BMD.

Wrist and elbow

Nonsurgical eECRB—In a systematic review and meta-analysis published in The American Journal of Sports Medicine (online), researchers found that nonoperative pain relief treatment options for enthesopathy of the extensor carpi radialis (eECRB) may increase the risk of AEs and provide little relief of pain. They reviewed 36 randomized, placebo-controlled trials that evaluated 11 different treatment options and included 2,746 patients. Only local corticosteroid improved short-term pain but was associated with worse pain than placebo at long-term follow-up. Laser therapy and local botulinum toxin injection relieved pain at midterm follow-up. At long-term follow-up, extracorporeal shock wave therapy alleviated pain. Only laser therapy outperformed placebo in improving grip strength. Compared to placebo, all treatment options increased the likelihood of AEs at similar rates. At short-term follow-up, 2 percent of patients receiving placebo reported mild pain compared to 92 percent at midterm follow-up.


Risk factors for mortality in femoral fractures—According to a retrospective review published in Injury (online), elderly, frail patients with an active malignancy are at the highest risk of mortality following periprosthetic proximal femoral fractures. Researchers queried the Fracture Outcomes Research Database for patients aged older than 60 years with periprosthetic hip fracture between 2007 and 2015. They identified 189 patients, most of whom (61.9 percent) had Vancouver B1 fractures. Most surgeries were cable plating (75.1 percent), 21.2 percent were revision arthroplasties, and 1.6 percent were proximal femoral replacements. Postoperatively, 27.3 percent of patients returned home. There were four (2.1 percent) deaths prior to surgery. The 30-day mortality rate was 2.1 percent, and one-year mortality was 11.6 percent. Older age was associated with increased mortality.

Patient preferences

Patient preference for outpatient care—According to a study published in the American Journal of Orthopedics (online), orthopaedic patients in the outpatient setting value short wait times and brief visits with their surgeons. A total of 196 patients from an adult reconstruction clinic completed the electronically administered survey. Most patients (41.3 percent) said they would like their doctors to spend 10 to 15 minutes with them during a visit; only 10.2 percent of patients said they would prefer more than 20 minutes. When asked about wait times, 83.1 percent said 30 minutes or more is too long. Patients had no demographic preferences for their physicians, but 41.8 percent said they would consider it below average care if they were seen only by a physician’s assistant or nurse practitioner during a postoperative visit. More than half of patients (66.4 percent) said they ask for recommendations from friends or other physicians when looking for doctors, and 12.2 percent reported using online rating sites.