JBJS Sample 2

Table of Content

1. Notable Articles of 2022

As we approached the close of 2022, I took the opportunity to reflect on the many important articles that we published over the course of the year, focusing specifically on those that will have the greatest impact on patient care. The range of topics that we covered is as broad as the worldwide distribution of centers from which they emanate. We learned of the long-term impact of patient obesity on revision rates following total knee replacement as well as the minimum 10 year outcomes of total ankle replacement. It is now clear that a mini-open procedure to place medial pins for the fixation of pediatric supracondylar fractures is safe and that magnetically controlled rods for early-onset scoliosis are promising but have a notable complication rate. The impact of higher perioperative supplemental oxygen concentrations on postoperative infection in patients with fractures is now clear, as is the impact of culture-negative prosthetic joint infection on patient outcomes. We now have a better understanding of bone turnover rates in premenopausal women with distal radial fractures as well as the long-term outcomes of open Latarjet procedures in patients with shoulder instability. Perhaps the most impactful publications are the 2 supplements that we published this year: one on the diagnosis, prevention, and treatment of VTE across all orthopaedic subspecialties, and another on the advantages and hazards of using administrative data sets and joint registries to study the outcomes of orthopaedic procedures. It is my hope that you will review these impactful research papers and incorporate the findings into your patient care decision-making.

Table of Content

2. What’s New in Hand and Wrist Surgery

In this update, the most interesting, relevant, and applicable findings from The Journal of Hand Surgery (European Volume),The Journal of Hand Surgery, HAND, and the Journal of Pediatric Orthopaedics , primarily from September 2021 through August 2022, have been summarized. The intent of this work is to serve as an update of the hand and wrist surgery literature for the practicing general orthopaedic surgeon. Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is one of the most common problems presenting to the hand surgeon. There has been a continued effort to refine the optimal diagnostic criteria for CTS. The Carpal Tunnel Syndrome-6 (CTS-6) is a validated 26-point scale that incorporates 6 aspects of the history and clinical examination to predict the probability of the presence of CTS 1 . Recent studies have shown that CTS-6 scores are similar whether they are applied by experienced or inexperienced individuals and when assessment is made via a telemedicine visit, indicating that the CTS-6 is easy to administer and reliable 2 , 3 . These findings suggest that the CTS-6 could be used to screen patients prior to a visit with the surgeon.

Table of Content

3. Tissue Integration and Chondroprotective Potential of Acetabular Labral Augmentation with Autograft Tendon: Study of a Porcine Model

Background: The aim of this study was to explore the tissue healing process and changes in articular cartilage following acetabular labral augmentation in a porcine model. Methods: The labrum was resected unilaterally from 10 o’clock to 1 o’clock on the capsular side in 36 pigs. Eighteen pigs underwent labral augmentation (AUG group) using autologous Achilles tendon. No additional procedures were performed in the remaining pigs (control group). The pigs were killed at 6, 12, or 24 weeks postoperatively for histological assessment and measurement of the inflammatory cytokines interleukin (IL)-6, IL- 1β, and tumor necrosis factor ( TNF)- α in synovial fluid. Results: All autografts were well placed in the labral defect in the AUG group, and good integration of the autograft with the remnant chondrolabral junction was observed at 24 weeks; only scar tissue was observed in the control group at 6, 12, and 24 weeks. Fibrochondrocytes were concentrated at the transition between the autograft and native labrum at early time points, and the cells within the autograft labrum were predominantly fibrochondrocytes at 24 weeks. Rough and irregular articular cartilage surfaces were observed in 3 of the 6 samples in the AUG group at 24 weeks; the others appeared smooth. Focal cartilage erosion (predominantly in the acetabulum) occurred in all samples in the control group at 12 and 24 weeks. The Mankin score at 24 weeks was significantly lower in the AUG group than in the control group (mean [95% confidence interval]: 2.33 [1.06 to 3.6] versus 9 [8.06 to 9.94], p < 0.001). Likewise, the concentrations of all cytokines (in pg/mL) were significantly lower in the AUG group than in the control group at 24 weeks (IL-6: 166.6 [155.22 to 177.94] versus 245.9 [242.66 to 249.14], p < 0.001; IL- 1β: 122.1 [116.4 to 127.83] versus 282.9 [280.29 to 285.51], p < 0.001; and TNF - α: 56.22 [53.15 to 59.29] versus 135 [131.66 to 138.24], p < 0.001). Conclusions: Autograft tendon used for labral augmentation was able to integrate well with the native labrum, which may help to preserve the articular cartilage.

Table of Content

4. Nationwide Results of Microorganism Antigen Testing as a Component of Preoperative Synovial Fluid Analysis

Background: Antigen immunoassays to detect synovial fluid (SF) microorganisms have recently been made available for clinical use. The purpose of this study was to determine the sensitivity and specificity of an SF microorganism antigen immunoassay detection (MID) panel, evaluate the panel’s capability to detect micr oorganisms in the setting of culture-negative periprosthetic joint infection (PJI), and determine diagnostic predictive values of the MID panel for PJI. Methods: This study included 67,441 SF samples obtained from a hip or knee arthroplasty, from 2,365 institutions across the United States, submitted to 1 laboratory for diagnostic testing. All data were prospectively compiled and then were analyzed retrospectively. Preoperative SF data were used to classify each specimen by the International Consensus Meeting (2018 ICM) definition of PJI: 49,991 were not infected, 5,071 were inconclusive, and 12,379 were infected. The MID panel, including immunoassay tests to detect Staphylococcus, Candida, and Enterococcus, was evaluated to determine its diagnostic performance. Results: The MID panel demonstrated a sensitivity of 94.2% for infected samples that yielded positive cultures for target microorganisms (Staphylococcus, Candida, or Enterococcus). Among infected samples yielding positive cultures for their respective microorganism, individual immunoassay test sensitivity was 93.0% for Staphylococcus, 92.3% for Candida, and 97.2% for Enterococcus. The specificity of the MID panel for samples that were not infected was 98.4%, yielding a false positive rate of 1.6%. The MID panel detected microorganisms among 49.3% of SF culture negative infected samples. For PJI as a diagnosis, the positive predictive value of the MID panel was 91.7% and the negative predictive value was 93.8%. Among MID-positive PJIs, 16.2% yielded a discordant cultured organism instead of that detected by the antigen test. Conclusions: SF microorganism antigen testing provides a timely adjunct method to detect microorganisms in the preoperative SF aspirate, yielding a low false-positive rate and enabling the detection of a microorganism in nearly one-half of SF culture-negative PJIs.

Table of Content

5. Quadriceps Strain and TKA: Contribution of the Tourniquet and Intramedullary Rod to Postoperative Thigh Pain: A Randomized Controlled Trial

Background: Thigh pain is relatively common after total knee arthroplasty (TKA) and has been attributed to compression of the thigh muscles by the tourniquet used during surgery. Thigh pain that occurs after a TKA that was performed without a tourniquet may be due to a strain of the quadriceps muscle or insertion of the intramedullary (IM) rod. The purpose of the present study was to determine the cause of thigh pain after TKA in a randomized controlled trial evaluating tourniquet use, IM rod use, and quadriceps strain. Methods: This prospective randomized controlled trial enrolled 97 subjects undergoing primary knee arthroplasty into 4 groups according to tourniquet use (yes or no) and IM rod use (yes or no). Quadriceps strain was evaluated with magnetic resonance imaging (MRI) on postoperative day 1 (POD 1). Data collected preoperatively, intraoperatively, and postoperatively until the 6-week clinical visit included pain levels for the knee and thigh (recorded separately) and knee range of motion. Results: Regardless of tourniquet or IM rod use, 73 (75%) of the 97 patients reported thigh pain on POD 1. Thigh pain at 2 weeks postoperatively was indicative of a quadriceps strain. Use of a tourniquet and patient-reported thigh pain at 2 weeks increased the odds of a quadriceps strain, whereas IM rod use did not significantly contribute to thigh pain. Conclusions: The etiology of thigh pain after TKA may be multifactorial; however, an iatrogenic quadriceps strain is one source of thigh pain after TKA, especially if the pain persists 2 weeks after surgery.

Table of Content

6. Cost Analysis of Conversion Total Knee Arthroplasty: A Multi-Institutional Database Study

Background: Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort. Methods: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics. Results: The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates. Conclusions: The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure.