The latest medical research on Orthopaedic Surgery

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about orthopaedic surgery gathered by our medical AI research bot.

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Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access.

JAMA Surgery

Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009.

To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use.

This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed.

Placement of an AVF or AVG for initial permanent hemodialysis access.

A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use.

A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution.

In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.

Comparison of Targeted vs Systematic Prostate Biopsy in Men Who Are Biopsy Naive: The Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) Study.

JAMA Surgery

Magnetic resonance imaging (MRI) guidance improves the accuracy of prostate biopsy for the detection of clinically significant prostate cancer, but the optimal use of such guidance is not yet clear.

To determine the cancer detection rate (CDR) of targeting MRI-visible lesions vs systematic prostate sampling in the diagnosis of clinically significant prostate cancer in men who were biopsy naive.

This paired cohort trial, known as the Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) study, was conducted in an academic medical center from January 2015 to April 2018. Men undergoing first-time prostate biopsy were enrolled. Paired-cohort participants were a consecutive series of men with MRI-visible lesions (defined by a Prostate Imaging Reporting & Data System version 2 score  ≥ 3), who each underwent 3 biopsy methods at the same sitting: first, a systematic biopsy; second, an MRI-lesion biopsy targeted by cognitive fusion; and third, an MRI-lesion targeted by software fusion. Another consecutive series of men without MRI-visible lesions underwent systematic biopsies to help determine the false-negative rate of MRI during the trial period.

The primary end point was the detection rate of clinically significant prostate cancer (Gleason grade group ≥2) overall and by each biopsy method separately. The secondary end points were the effects of the Prostate Imaging Reporting & Data System version 2 grade, prostate-specific antigen density, and prostate volume on the primary end point. Tertiary end points were the false-negative rate of MRI and concordance of biopsy-method results by location of detected cancers within the prostate.

A total of 300 men participated; 248 had MRI-visible lesions (mean [SD] age, 65.5 [7.7] years; 197 were white [79.4%]), and 52 were control participants (mean [SD] age, 63.6 [5.9] years; 39 were white [75%]). The overall CDR was 70% in the paired cohort group, achieved by combining systematic and targeted biopsy results. The CDR by systematic sampling was 15% in the group without MRI-visible lesions. In the paired-cohort group, CDRs varied from 47% (116 of 248 men) when using cognitive fusion biopsy alone, to approximately 60% when using systematic biopsy (149 of 248 men) or either fusion method alone (154 of 248 men), to 70% (174 of 248 men) when combining systematic and targeted biopsy. Discordance of tumor locations suggests that the different biopsy methods detect different tumors. Thus, combining targeting and systematic sampling provide greatest sensitivity for detection of clinically significant prostate cancer. For all biopsy methods, the Prostate Imaging Reporting & Data System version 2 grade and prostate-specific antigen density were directly associated with CDRs, and prostate volume was inversely associated.

An MRI-visible lesion in men undergoing first-time prostate biopsy identifies those with a heightened risk of clinically significant prostate cancer. Combining targeted and systematic biopsy offers the best chances of detecting the cancer.

Role of Hepatic Artery Infusion Chemotherapy in Treatment of Initially Unresectable Colorectal Liver Metastases: A Review.

JAMA Surgery

Although liver metastasis develops in more than half of patients with colorectal cancer, only 15% to 20% of these patients have resectable liver metastasis at presentation. Moreover, patients with initially unresectable colorectal liver metastasis (IU-CRLM) who progress on first-line systemic chemotherapy have limited treatment options. Hepatic arterial infusion chemotherapy (HAIC), in combination with systemic chemotherapy, leverages a multimodality approach to achieving control of hepatic disease and/or expanding resectability in patients with liver-only disease or liver-dominant disease.

Intra-arterial delivery of agents with high first-pass hepatic extraction (eg, floxuridine) limits systemic toxic effects and allows for administration of systemic chemotherapy at near-full doses. Hepatic arterial infusion chemotherapy in conjunction with systemic chemotherapy augments response rates up to 92% in patients who are chemotherapy naive, and up to 85% in pretreated patients with IU-CRLM. In turn, these responses translate into encouraging rates of conversion to resectability (CTR). Prospective trials have reported CTR rates as high as 52% in heavily pretreated patients with IU-CRLM who have an extensive hepatic disease burden. As such, CTR remains a compelling indication for liver-directed chemotherapy in this subset of patients. This review discusses the biological rationale for HAIC, evolution of rational combinations with systemic chemotherapy, contemporary evidence for CTR using HAIC and systemic chemotherapy, juxtaposition with rates of CTR using systemic chemotherapy alone, and morbidity and toxic effect profiles of HAIC.

The argument is made for consideration of earlier initiation of HAIC in patients with IU-CRLM who are chemotherapy naive and for adoption of HAIC strategies to augment rates of resectability in patients who have failed first-line systemic chemotherapy before proceeding to second-line or third-line regimens.

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer.

JAMA Surgery

Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days.

To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs.

This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018.

Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias.

Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis.

Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Contributors to Postinjury Mental Health in Urban Black Men With Serious Injuries.

JAMA Surgery

Physical injury is associated with postinjury mental health problems, which typically increase disability, cost, recidivism, and self-medication for symptoms.

To determine risk and protective factors across the life span that contribute to depression and posttraumatic stress symptom severity at 3 months after hospital discharge.

This prospective cohort study used a 3-month postdischarge follow-up of patients who had been treated at an urban, level 1 trauma center in the Northeastern United States. Men with injuries who were hospitalized, self-identified as black, were 18 years or older, and resided in the Philadelphia, Pennsylvania, region were eligible and consecutively enrolled. Those who were experiencing a cognitive dysfunction or psychotic disorder, hospitalized because of attempted suicide, or receiving current treatment for depression or posttraumatic stress disorder (PTSD) were excluded. Data were collected from January 2013 to October 2017. Data analysis took place from January 2018 to August 2018.

A serious injury requiring hospitalization; adverse childhood experiences, childhood neighborhood disadvantage, and preinjury physical and mental health; and emotional resources, injury intent, and acute stress responses.

Depression and PTSD symptom severity were assessed with the Quick Inventory of Depressive Symptoms-Self-report and the PTSD Check List-5. The a priori hypothesis was that risk and protective factors are associated with depression and PTSD symptom severity. The analytic approach was structural equation modeling.

A total of 623 black men were enrolled. Of these, 502 participants (80.6%) were retained at 3-month follow-up. Their mean (SD) age was 35.6 (14.9) years; 346 (55.5%) had experienced intentional injuries, and the median (range) Injury Severity Score was 9 (1-45). Of the 500 participants with complete primary outcome data, 225 (45.0%) met the cut point criteria for mental health diagnoses at 3 months. For both mental health outcomes, the models fit the data well (depression: root mean square error of approximation [RMSEA], 0.044; comparative fit index [CFI], 0.93; PTSD: RMSEA = 0.045; CFI = 0.93), and all hypothesized paths were significant and in the hypothesized direction. Outcomes were associated with poor preinjury health (standardized weights: depression, 0.28; P < .001; PTSD, 0.17; P = .02), acute psychological reactions (depression, 0.34; PTSD, 0.38; both P < .001), and intentional injury (depression, 0.16; PTSD, 0.24; both P < .001). Acute psychological reactions were associated with childhood adversity (depression, 0.33; PTSD, 0.36; both P < .001). A history of prior mental health challenges (depression, 0.70; PTSD, 0.70; both P < .001) and psychological or emotional health resources (depression, -0.22; PTSD, -0.23; both P = .003) affected poor preinjury health, which was in turn associated with acute psychological reaction (depression, 0.44; PTSD, 0.42; both P < .001).

The intersection of prior trauma and adversity, prior exposure to neighborhood disadvantage, and poorer preinjury health and functioning are important, even in the midst of acute medical care for traumatic injury. These results support the importance of trauma-informed health care and focused assessment to identified patients with injuries who are at highest risk for poor postinjury mental health outcomes.

Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs.

JAMA Surgery

Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.

The Society of Surgical Chairs conducted a panel discussion at its 2017 annual meeting and a subsequent survey of its membership in 2018 to develop recommendations for the transitioning of the senior surgeon.

Recommendations include mandatory cognitive and psychomotor testing of surgeons by at least age 65 years, potentially as a component of ongoing professional practice evaluation; career transition discussions with surgeons beginning early in their careers; respectful consideration of the potential financial needs, long-standing work commitments, and work-life concerns of retiring surgeons; and creation of teaching, mentoring or coaching, and/or administrative opportunities for senior surgeons in modified clinical or nonclinical roles. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.

Fracture Risk After Roux-en-Y Gastric Bypass vs Adjustable Gastric Banding Among Medicare Beneficiaries.

JAMA Surgery

Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and may increase fracture risk, whereas substantial bone loss and increased fracture risk have not been reported after adjustable gastric banding (AGB). Previous studies have had little representation of patients aged 65 years or older, and it is currently unknown how age modifies fracture risk.

To compare fracture risk after RYGB and AGB procedures in a large, nationally representative cohort enriched for older adults.

This population-based retrospective cohort analysis used Medicare claims data from January 1, 2006, to December 31, 2014, from 42 345 severely obese adults, of whom 29 624 received RYGB and 12 721 received AGB. Data analysis was performed from April 2017 to November 2018.

The primary outcome was incident nonvertebral (ie, wrist, humerus, pelvis, and hip) fractures after RYGB and AGB surgery defined using a combination of International Classification of Diseases, Ninth Edition and Current Procedural Terminology 4 codes.

Of 42 345 participants, 33 254 (78.5%) were women. With a mean (SD) age of 51 (12) years, recipients of RYGB were younger than AGB recipients (55 [12] years). Both groups had similar comorbidities, medication use, and health care utilization in the 365 days before surgery. Over a mean (SD) follow-up of 3.5 (2.1) years, 658 nonvertebral fractures were documented. The fracture incidence rate was 6.6 (95% CI, 6.0-7.2) after RYGB and 4.6 (95% CI, 3.9-5.3) after AGB, which translated to a hazard ratio (HR) of 1.73 (95% CI, 1.45-2.08) after multivariable adjustment. Site-specific analyses demonstrated an increased fracture risk at the hip (HR, 2.81; 95% CI, 1.82-4.49), wrist (HR, 1.70; 95% CI, 1.33-2.14), and pelvis (HR, 1.48; 95% CI, 1.08-2.07) among RYGB recipients. No significant interactions of fracture risk with age, sex, diabetes status, or race were found. In particular, adults 65 years and older showed similar patterns of fracture risk to younger adults. Sensitivity analyses using propensity score matching showed similar results (nonvertebral fracture: HR 1.75; 95% CI, 1.22-2.52).

This study of a large, US population-based cohort including a substantial population of older adults found a 73% increased risk of nonvertebral fracture after RYGB compared with AGB, including increased risk of hip, wrist, and pelvis fractures. Fracture risk was consistently increased among RYGB patients vs AGB across different subgroups, and to a similar degree among older and younger adults. Increased fracture risk appears to be an important unintended consequence of RYGB.

Have the frequency of and reasons for revision total knee arthroplasty changed since 2000? Comparison of two cohorts from the same hospital: 255 cases (2013-2016) and 68 cases (1991-1998).

Orthop Traumatol Surg

The number of total knee arthroplasty (TKA) revisions is expected to increase 601% in the United States between 2005 and 2030. This type of information is not available in France, and the last national study on this topic was done in 2000. This led us to perform a comparative study to determine if 1) the frequency of TKA revisions has increased and 2) the reasons for reoperation have changed relative to data gathered in 2000 at a single hospital in France.

The frequency of TKA revision has increased between the two studies, performed 15 years apart.

II, comparative study.

Between 2013 and 2016, 349 TKA revisions were performed, and 255 met the inclusion criteria. Note that the historical cohort had 68 cases. The mean time elapsed between the primary TKA and revision procedure was 5.3 years [34 days to 31 years]. Eight reasons for reoperation were identified. Aseptic loosening (85 cases (33.3%)), stiffness (70 cases (27.5%)), tibiofemoral laxity (39 cases (15.3%)) and patellar complications (34 cases (13.3%)) were the four most common reasons for reoperation. The frequency has changed over time: relative to 2000, the annual frequency increased by a factor of 6.5. The reasons have also changed over time: there was an increase in revisions for aseptic loosening (33.3% vs. 23.5%), stiffness (27.5% vs. 20.6%) and knee joint laxity (15.3% vs. 10.3%). Conversely, there was a reduction in revisions for patellar complications (13.3% vs. 26.5%), unexplained pain (0.4% vs. 8.8%) and patellar clunk syndrome (1.2% vs. 4.4%).

The number of TKA revisions has increased by a factor of 6.5, with aseptic loosening still being the most common reason. The number of revisions performed for stiffness and knee joint laxity have increased. Fewer revisions are being done for unexplained pain because surgeons are now better able to determine the cause of TKA-related pain. There were fewer patella-related complications because of technical progress. The data generated from our single-center study are consistent with current published data.

Obesity may be a risk factor for recurrent heterotopic ossification in post-traumatic stiff elbow among children and teenagers.

Orthop Traumatol Surg

Post-traumatic elbow stiffness and heterotopic ossification (HO) affects long-term life quality, as commonly in children and teenagers as in grownups. Childhood obesity considerably influences public health because it causes stroke, hypertension and diabetes mellitus. Previous research discussed its clinical complications in orthopedic diseases. However, no clinical research reveals the interaction between childhood obesity and HO after elbow injuries.

Obesity might be a risk factor of recurrent HO after elbow arthrolysis in children and teenagers, correlated with the severity of postoperative HO.

III, retrospective cohort study, treatment study.

The mean age, gender, pathogenesis, side of injury, time of injury, follow-up duration were analyzed. Overweight/obese children and teenagers were more likely to develop recurrent HO (p=0.005) than underweight/normal-weight children and teenagers. A significant difference in the severity of recurrent HO between two groups was confirmed (p=0.028). The range of motion was improved greatly in underweight/normal-weight group compared with that in overweight/obese group (p=0.001).

The HO recurrence difference between two groups confirmed the hypothesis. Although underlying mechanisms are unclear, weight control might promote postoperative and long-term rehabilitation of the elbow joint for children and teenagers.

Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases.

Orthop Traumatol Surg

Clavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis.

Clavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients.

IV, retrospective observational study.

Mean follow-up was 3.9 years (range, 1-8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3-5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin.

When used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods.

Dental assessment prior to orthopedic surgery: A systematic review.

Orthop Traumatol Surg

To reduce the risk of infection after orthopedic surgery, patients are asked to undergo preoperative assessments in various medical domains. However, to our knowledge, there has been no systematic review to evaluate the performance of a preoperative dental assessment before orthopedic surgery. We focus on two questions as follows: (1) is there a link between the presence of preoperative dental assessment and orthopedic infections?; (2) is the probability of an orthopedic infection increased in the presence of dental risk factors and comorbidities?

Level III, systematic review.

Based on eligibility criteria, 12 case series, 4 case-control studies and 12 cohort studies were included. In case-controls, prosthesis infection was presumably associated with a dental abscess in 6/224 of cases (2.9%). In cohort studies, exposure was defined as "any dental assessment or dental treatment performed before surgery". Even if only 4 cohort studies provide this information exposure, it would seem that the presence of an infectious complication is less frequent if the preoperative examination has been performed. Dental treatment given before surgery was mainly for scaling-polishing in 78/205 (38%), extraction in 49/205 of cases (24%) and restorative work in 37/205 (18%).

The literature review was made complex by the substantial heterogeneity among included studies. Although there is no formal evidence for or against preoperative dental assessment, it is advisable to perform this with the aim of maintaining favorable oral hygiene and thus reduce the risk factors.

Immediate and late discal lesions on MRI in Magerl A thoracolumbar fracture: Analysis of 76 cases.

Orthop Traumatol Surg

Magerl type A thoracolumbar fracture is frequent, but consensus is lacking on management, which ranges from non-operative treatment to corpectomy. It is, however, essential to spare adjacent discs in young patients. Historically, Magerl defined type A fracture in terms of isolated bone involvement. Subsequently, several authors suggested that discal lesions are associated, but results were inconsistent. The present study assessed the presence of immediate post-trauma discal lesions and late degeneration.

Type A fracture does not entail discal lesion.

IV, retrospective study.

Immediate post-trauma analysis of the cranial discs of the fractured vertebrae found 81% normal (type 1), none type 2, 7% type 3, 4% type 4, 7% type 5 and 1% type 6. Caudal discs were 97% type 1. Analysis at follow-up found degeneration in only 15% of cranial and 9% of caudal discs.

A large majority of type A fractures lead to no immediate discal lesions, and only 15% of cranial discs subsequently degenerate. MRI analyzing disc signal and morphology is essential before removing material.