Socio-economics Trumps Design in TKA Outcomes…and More

Socio-economics Trump Design in TKA Outcomes

Ryan Nunley, M.D. is assistant professor of orthopedics at Washington University in St. Louis. He has recently done research on the impact of socio-economic factors on results of total knee arthroplasty. Dr. Nunley tells OTW, “All implant companies have different designs and different types, whether fixed bearing or mobile, gender specific or not. When you compare total hips to total knees, it has been established that total hips perform better as far as pain relief. (90-95% versus 80-85% for patient overall satisfaction after surgery) So we wanted to know how we could create better options for knees. We found that when we compared implant types via multivariate analysis the only thing that bore out were the secondary factors (socio-economic, education level, etc.). That means that it might not matter as much about the implant design as previously debated, because the knee implant isn’t the predominant factor. We were very surprised by our findings. In the literature various articles talk about one implant being superior to another; the fact is that most peer reviewed articles don’t report socio-economic factors…so we are going back and examining these studies. This is important work, and I am pleased that it has been nominated for several awards. What I don’t want to happen, however, is that we start avoiding arthritis patients who are less educated, poor or who are minorities because we think they might have a poor outcome.”

Watch This Space – PTOA Clues for Osteoarthritis

Commander Matthew T. Provencher, M.D., M.C., U.S.N. is Director of Orthopaedic Shoulder, Knee, and Sports Surgery at the Naval Medical Center San Diego Department of Orthopaedic Surgery. He is also Professor of Surgery and Orthopaedics at the Uniformed Services University of Health Sciences. Dr. Provencher tells OTW, “My colleagues and I are very excited about the progress we’re making with post traumatic osteoarthritis (PTOA). This is not just a condition related to major trauma, but it results from athletic injuries throughout high school, college, and thereafter. Research in this area is increasingly focused on preventing PTOA—and its basic science, cartilage work, metabolism research, as well as translational and clinical trials. Many researchers have been making progress with the prevention of PTOA in animal models; the next phase is look at the disease modifying trials. We must concurrently look at the animal, the basic science, and the natural history perspective to truly see our future impact.”

“Our group is looking at longitudinal studies (at what happens after sports trauma). But the real key is to have multi center trials and established multi center networks that can look at aggregated data and see where we can have an impact and also determine what agents will be highest impact and at which point in the disease. For example, although preliminary, we did find that the longer patients have shoulder instability, the more cartilage and soft tissue injuries they present with. We need to find ways in which to modify this progression and we hope that in a year from now we will have a lot more historical data and we will be much close to disease modification.”

Robert F. LaPrade M.D., Ph.D. Wins OREF Award

The American Academy of Orthopaedic Surgeons and the Orthopaedic Research and Education Foundation (OREF), has announced that Dr. Robert LaPrade has been awarded the 2013 OREF Clinical Research Award for his paper, “Improving Outcomes for Posterolateral Knee Injuries.” Dr. LaPrade will be presenting his winning paper at the Annual Meetings of the Orthopaedic Research Society and the American Academy of Orthopaedic Surgeons in 2013. In addition to the posterolateral knee for which this award was based, Dr. LaPrade and his team of collaborators have similar ongoing programs in place for the medial knee and MCL, anterior cruciate ligament, and posterior cruciate ligament.

50% Infection Jump From Embolizing Veins?

Andrew Pollak, M.D. is chief of the Division of Orthopaedic Traumatology and associate director of Trauma at the R Adams Cowley Shock Trauma Center. He tells OTW, “I worked with Ted Manson, M.D. on a recently published article on complications after embolization of pelvic arterial injuries. These patients are bleeding rapidly and in shock—extremis—and in addition to stabilizing their pelvic ring injuries, they are often treated with angiographic embolization of their pelvic arterial system in order to control hemorrhage. Rather than selectively embolize the artery that is bleeding, interventional radiologists will occasionally embolize proximal vessels the one proximal to that, arguing that collateral flow will limit the risk of distal muscle death. Their experience in large numbers of patients is that it is safe. However, our study found that in a subset of patients who underwent surgery later for an associated acetabulum fracture the risk of infection increases—up to 50%. This is a warning to all of us that if a patient has had embolization of the vascular tree, be careful. Surgeons treating these patients during their initial resuscitation should pay particular attention to this…the risk/benefit assessment with regard to later operative treatment of their acetabulum fracture changes considerably.”

Placebo Beat HA in Thumb Arthritis Study

Lisa Mandl, M.D., MPH is a rheumatologist at Hospital for Special Surgery. She recently led a randomized, double-blind clinical trial which revealed that corticosteroids are more effective than Hylan G-F 20 in providing pain relief to patients with thumb arthritis. The team also found that while both of these treatments provided pain relief, so did a placebo injection. “Our study is the first large randomized clinical trial in patients with carpometacarpal (CMC) osteoarthritis (thumb arthritis). My interest in this topic started during my fellowship. I had begun to notice a lot of older patients who were looking forward to retiring and being active, but who were severely affected by arthritis at the base of the thumb. It was actually their ruining their lives; their sleep was disturbed, regular activities were painful and/or difficult…yet nothing else was wrong with them. They had tried nonsteroidals, splinting, and steroid injections, but they were still miserable. They didn’t want surgery, and I was struck by the fact that there was nothing else out there to help them. I got the idea that perhaps Hylan G-F 20—a product approved by the FDA for knee OA—might be helpful.”

“We had 200 patients with thumb arthritis, and they received either bupivacaine, Hylan G-F 20, or triamcinolone. We were very surprised to learn that nothing worked better than placebo; in fact, some patients had phenomenal responses to bupivacaine. Bupivacaine shouldn’t do anything…just numb the area and wear off in 20 minutes…but even that was helpful for some patients. It may be that the injection itself is making people feel better.”

“This was essentially a negative trial. The take home message here is that if you have exhausted conservative therapies, try steroids first. If the patient is very risk averse you might try bupivacaine. In patients who are miserable and refuse to have surgery, I would still try Hylan G-F 20 as a last resort.”

Charles Blitzer, M.D. Given Humanitarian Award

Charles Blitzer, M.D. of Seacoast Orthopedics and Sports Medicine in Somersworth has been presented the Humanitarian Award by the New Hampshire Orthopaedic Society, the state organization committed to bringing together orthopedic physicians to work for the benefit of patients and the profession.
The N.H. Orthopaedic Society Humanitarian Award recognizes orthopedic surgeons in the state who have distinguished themselves through outstanding musculoskeletal care and community service in New Hampshire and/or abroad. Dr. Blitzer is an orthopedic surgeon, specializing in trauma and fracture care, who has been in practice in New Hampshire for 28 years.

Lowest Infection Rate Winner – Hospital for Special Surgery (HSS)!

For the fourth year in a row, HSS is being lauded for having an infection rate that is significantly lower than the New York State average for hip replacement or revision surgeries. Surgeons at Hospital for Special Surgery performed the most hip replacement surgeries in New York State, with nearly 4, 200 procedures, which is about 15% of the approximate 27, 000 hip replacement or revision procedures in New York State in 2011. Among the 167 hospitals included in the report, Hospital for Special Surgery had a statistically lower surgical site infection rate of 0.4% compared with the state average of 1.12% for total hip replacement or revision hip procedures. How do they do this? First of all, an electronic data monitoring program serves as a “first alert” system for new cultures and organisms that could pose a threat to patient safety. Patients’ exposure to contaminants is minimized, because they are isolated from the surgical environment by a specially designed Plexiglas enclosure, which helps to improve air flow and to restrict excess personnel at the surgical field. After surgery, the operating rooms are meticulously cleaned by staff that is regularly monitored for competency by the infection control nurse.