John Wright

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

BACKGROUNDnWhether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain.nnnMETHODSnWe conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization.nnnRESULTSnIn the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups.nnnCONCLUSIONSnIn the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.).

Risk factors for revision of primary total hip arthroplasty: a systematic review

BackgroundNumerous papers have been published examining risk factors for revision of primary total hip arthroplasty (THA), but there have been no comprehensive systematic literature reviews that summarize the most recent findings across a broad range of potential predictors.MethodsWe performed a PubMed search for papers published between January, 2000 and November, 2010 that provided data on risk factors for revision of primary THA. We collected data on revision for any reason, as well as on revision for aseptic loosening, infection, or dislocation. For each risk factor that was examined in at least three papers, we summarize the number and direction of statistically significant associations reported.ResultsEighty-six papers were included in our review. Factors found to be associated with revision included younger age, greater comorbidity, a diagnosis of avascular necrosis (AVN) as compared to osteoarthritis (OA), low surgeon volume, and larger femoral head size. Male sex was associated with revision due to aseptic loosening and infection. Longer operating time was associated with revision due to infection. Smaller femoral head size was associated with revision due to dislocation.ConclusionsThis systematic review of literature published between 2000 and 2010 identified a range of demographic, clinical, surgical, implant, and provider variables associated with the risk of revision following primary THA. These findings can inform discussions between surgeons and patients relating to the risks and benefits of undergoing total hip arthroplasty.

Association of serum sodium with morbidity and mortality in hospitalized patients undergoing major orthopedic surgery

BACKGROUNDnDysnatremia may predispose to falls and fractures, and serum sodium may influence bone health. Little is known of the association of perioperative dysnatremia and clinical outcomes in those undergoing major orthopedic surgery.nnnOBJECTIVEnWe examined the association of serum sodium (corrected for glucose) with morbidity and mortality in a sample of hospitalized patients undergoing major orthopedic procedures at 2 large academic medical centers.nnnDESIGNnRetrospective observational study.nnnSETTING AND PARTICIPANTSnAdult patients admitted to major academic teaching hospitals for a major orthopedic procedure from January 2006 to January 2011.nnnMETHODSnThe association of serum sodium with log-transformed hospital length of stay was assessed by fitting linear regression models. The association with 30-day mortality was assessed by fitting Cox proportional hazards models.nnnRESULTSnThere were 16,206 unique admissions, of which 44.8% were male, with a mean age of 62.5 years. Mean corrected serum sodium was 138.5 ± 2.9 mmol/L; 1.2% had moderate/severe hyponatremia, 6.4% had mild hyponatremia, and 2.5% were hypernatremic. In adjusted models, compared with normonatremia, moderate/severe hyponatremia, mild hyponatremia, and hypernatremia were associated with a 1.6-, 1.4-, and 1.4-day-longer hospital stay, respectively, and greater risk of 30-day mortality (hazard ratio [HR]: 2.47, 95% confidence interval [CI]: 1.33-4.59 for moderate/severe hyponatremia; HR: 1.80, 95% CI: 1.21-2.66 for mild hyponatremia; and HR: 2.99, 95% CI: 1.79-4.98 for hypernatremia).nnnCONCLUSION AND RELEVANCEnDysnatremia is relatively common in the hospitalized orthopedic population and associated with greater length of stay and 30-day mortality. Future studies should address potential mechanisms underlying these associations and whether correction of perioperative dysnatremia may improve patient outcomes.

Patient- and surgeon-adjusted control charts for monitoring performance

Objectives To determine whether an innovative graphical tool for accurate measurement of individual surgeon performance metrics, adjusted for both surgeon-specific and patient-specific factors, significantly alters interpretation of performance data. Design Retrospective analysis of all total knee replacements (TKRs) conducted at the host institution between 1996 and 2009. The database was randomly divided into training and testing datasets. Using multivariate generalised estimating equation regression models, the training dataset enabled generation of patient-risk and surgeon-experience adjustment factors. To simulate prospective monitoring of individual surgeon outcomes, the testing dataset was mapped on control charts. Weighted κ statistics were calculated to measure the agreement between patient-risk adjusted and fully adjusted control charts. Setting Tertiary care academic hospital. Participants All patients undergoing TKR at the host institution 1996–2009. Main outcome measure Operative efficiency. Results 5313 procedures were analysed. Adjusted control charts were generated using a training dataset comprising 3756 procedures performed by 13 surgeons. The operative time gradually declined by 121u2005min with 25u2005years of experience (p<0.0001). Charts were tested by monitoring four other surgeons, performing an average of 389 procedures each. Adjustment for surgeon experience significantly altered the interpretation of operative efficiency (κ=0.29 (95% CI 0.11 to 0.47)), and enhanced assessment of a surgeons improvement or diminishment in efficiency over time. Specifically, experience adjustment inverted the interpretation of surgeon efficiency from above average to below average, or from improving to declining performance. Conclusions Adjustment for surgeon experience is necessary for accurate interpretation of metrics over the course of a surgeons career. Patient-adjusted and surgeon-adjusted control charts provide an accurate method of monitoring individual operative efficiency.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis

BACKGROUNDnThe choice between anterior approach (AA) and posterior approach (PA) in primary total hip arthroplasty (THA) is controversial. Previous reviews have predominantly relied on data from retrospective studies.nnnMETHODSnThis systematic review included prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA. Outcomes were pain severity, narcotic usage, hip function using Harris Hip Score, and complications. Random effects meta-analysis was performed for all outcomes. Efficacy data were reported as standardized mean difference (SMD) where values of 0.2, 0.5, 0.8, and 1.0 were defined as small, medium, large, and very large effect sizes, respectively. Complications were reported as the absolute risk difference (RD) where a positive value implied higher risk with AA and a lower value implied lower risk with AA.nnnRESULTSnA total of 13 prospective comparative studies (7 randomized) with patients treated with AA (nxa0=xa0524) or PA (nxa0= 520) were included. The AA was associated with lower pain severity (SMDxa0=xa0-0.37, P <xa0.001), lower narcotic usage (SMDxa0=xa0-0.36, Pxa0= .002), and improved hip function (SMDxa0= 0.31, Pxa0=xa0.002) compared to PA. No differences between surgical approaches were observed for dislocation (RDxa0= 0.2%, Pxa0= .87), fracture (RDxa0= 0.2%, Pxa0= .87), hematoma (RDxa0= 0%, Pxa0= .99), infection (RDxa0= 0.2%, Pxa0=xa0.85), thromboembolic event (RDxa0=xa0-0.9%, Pxa0= .42), or reoperation (RDxa0= 1.3%, Pxa0= .26). Conclusions of this study were unchanged when subjected to sensitivity analyses.nnnCONCLUSIONnIn this systematic review and meta-analysis of prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA, patients treated with AA reported less pain, consumed fewer narcotics, and reported better hip function. No statistical differences in complication rates were detected between AA and PA. Ultimately, the choice of surgical approach in primary THA should consider preference and experience of the surgeon as well as preference and anatomy of the patient.

Conjunctival Biopsy in Patients with Kawasaki Disease

Kawasaki disease (KD) is an acute vasculitis of infants and young children that is associated with bilateral nonexudative conjunctivitis during the acute illness. Epidemiologic evidence has suggested an infectious cause but the etiology of KD remains unknown. We examined conjunctival biopsy specimens from seven patients with typical KD to characterize the pathologic changes during the acute disease. Light microscopic examination revealed nonspecific, mild inflammatory changes that included vascular dilatation, infiltration with scattered lymphocytes, increased numbers of plasma cells in the conjunctival stroma, and increased prominence of goblet cells in the epithelium. No pathogens were identified by special stains for bacteria and rickettsiae, nor were viral particles seen by electron microscopy. We conclude that the conjunctivitis of acute KD is characterized by vascular dilatation with a mild mononuclear cell response with no pathognomonic features. The conjunctiva can be readily sampled in these patients and biopsy may prove useful in selected patients to exclude other clinical entities in the differential diagnosis.

The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis

Summary Objectives The independent impact of individual surgical experience and team familiarity on surgical performance has been widely studied; however, the interplay of these factors and their relative, quantified, contributions to performance is poorly understood. We determined the impact of team familiarity and surgeon, and cumulative team experience on operative efficiency in total knee replacement. Design Retrospective analysis of all total knee replacements conducted at the host institution in 1996–2009. Multivariate generalised-estimating-equation regression models were used to adjust for patient risk and clustering. Setting Tertiary care academic hospital. Participants All patients undergoing TKR at the host institution in 1996–2009. Main outcome measure Operative efficiency. Results A total of 4276 total knee replacements were completed by 1163 different surgical teams. The median experience level was 17.6 years for consultant surgeons and 3.7 years for trainee surgeons. After patient-risk adjustment, consultant surgical experience (pu2009<u20090.0001), trainee surgical experience (pu2009<u20090.05), cumulative team operative experience (pu2009<u20090.0001) and team familiarity (pu2009<u20090.0001) were associated with significant reductions in operative time. Surgical experience and team familiarity demonstrated concave and linear relationships with operative time, respectively. For a consultant surgeon, the expected reduction in operative time after 25 years in practice was 51u2009min, compared to a 21-min reduction over the span of 40 collaborations with the same team members. Conclusions Surgical experience and team familiarity display important and distinct relationships with operative time in total knee replacement. Appreciation of this interplay may serve to guide implementation and allocation of procedure-specific quality improvement strategies in surgery.

Acetabular and Labral Pathology

Summary The cadaveric data show that labral lesions are extremely common, present in 93% of specimens.

Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis: A Randomized Trial Comparing Physical Therapy and Surgery

BACKGROUNDnArthroscopic partial meniscectomy (APM) combined with physical therapy (PT) have yielded pain relief similar to that provided by PT alone in randomized trials of subjects with a degenerative meniscal tear. However, many patients randomized to PT received APM before assessment of the primary outcome. We sought to identify factors associated with crossing over to APM and to compare pain relief between patients who had crossed over to APM and those who had been randomized to APM.nnnMETHODSnWe used data from the MeTeOR (Meniscal Tear in Osteoarthritis Research) Trial of APM with PT versus PT alone in subjects ≥45 years old who had mild-to-moderate osteoarthritis and a degenerative meniscal tear. We assessed independent predictors of crossover to APM among those randomized to PT. We also compared pain relief at 6 months among those randomized to PT who crossed over to APM, those who did not cross over, and those originally randomized to APM.nnnRESULTSnOne hundred and sixty-four subjects were randomized to and received APM and 177 were randomized to PT, of whom 48 (27%) crossed over to receive APM in the first 140 days after randomization. In multivariate analyses, factors associated with a higher likelihood of crossing over to APM among those who had originally been randomized to PT included a baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Score of ≥40 (risk ratio [RR] = 1.99; 95% confidence interval [CI] = 1.00, 3.93) and symptom duration of <1 year (RR = 1.74; 95% CI = 0.98, 3.08). Eighty-one percent of subjects who crossed over to APM and 82% of those randomized to APM had an improvement of ≥10 points in their pain score at 6 months, as did 73% of those who were randomized to and received only PT.nnnCONCLUSIONSnSubjects who crossed over to APM had presented with a shorter symptom duration and greater baseline pain than those who did not cross over from PT. Subjects who crossed over had rates of surgical success similar to those of the patients who had been randomized to surgery. Our findings also suggest that an initial course of rigorous PT prior to APM may not compromise surgical outcome.nnnLEVEL OF EVIDENCEnPrognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The AViKA (Adding Value in Knee Arthroplasty) postoperative care navigation trial: rationale and design features

BackgroundUtilization of total knee arthroplasty is increasing rapidly. A substantial number of total knee arthroplasty recipients have persistent pain after surgery. Our objective was to design a randomized controlled trial to establish the efficacy of a motivational-interviewing-based telephone intervention aimed at improving patient outcomes and satisfaction following total knee arthroplasty.Methods/DesignThe study was conducted at Brigham and Women’s Hospital in Boston, Massachusetts. The study focused on individuals 40 years or older with a primary diagnosis of osteoarthritis who were scheduled for total knee arthroplasty. The study compared two management strategies over the first six months postoperatively: 1) enhanced postoperative care with frequent follow-up by a care navigator; 2) usual postoperative care. Those who were randomized into the enhanced postoperative care arm received ten calls from a trained non-clinician care navigator over the first six postoperative months. The navigator used motivational interviewing techniques to engage patients in discussions related to their rehabilitation goals, including patient’s plans for and confidence in achieving those goals. Patients in the usual care arm received standard postoperative management and received no navigator phone calls. Patients in both arms were assessed at baseline, three months, and six months postoperatively.DiscussionThe primary outcome of the study was improvement in function as measured by the difference in Western Ontario and McMaster Universities Osteoarthritis Index function score between preoperative (baseline) status and six months postoperatively. Data were collected to identify factors that may be related to total knee arthroplasty outcomes, including preoperative pain, pain catastrophizing, self-efficacy, and depression. A formal economic analysis is also planned to determine the cost-effectiveness of the care navigator as a component of total knee arthroplasty care.Trial registrationClinicalTrials.govNCT01540851