Listen to Tim Coughlin and Brett Rocos discuss the paper 'The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data', followed by a summary of the April Round-ups.
Paper discussed:
Badhiwala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021;20(2)117–126. Crossref.
Listen to Tim Coughlin and Brett Rocos discuss the paper 'The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data', followed by a summary of the April Round-ups.
Paper discussed:
Badhiwala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021;20(2)117–126. Crossref.
[00:00:00] Welcome to the BJ360 Podcast for April, 2021, the journal edition. So today, we're going to be speaking to Brett Rocos who's one of our deputy editors and author of our editorial article this month. And then we're going to pick out some select papers from this month's edition across all of our Roundups.
I'm here with Brett Rocos who's our deputy editor at Bone & Joint 360 and the author of our editorial piece in this month's journal. And we're going to briefly discuss the paper Badhiwala et al published in Lancet neurology, I think in the February volume from this year. So Brett, just give us a summary of the paper and what your thoughts were.
Yeah. So this is a great paper. This is a derivation of the trials that have gone before that started to move us towards early operating and early decompression in spinal cord injury. And what this has done is taken those original [00:01:00] data sets and effectively reanalyzed them to look, to see if there's a better improvement in neurological function if you operate before 24 hours, rather than after 24 hours. And there's some things that make this really quite a potentially practice changing paper. This is their methodology. They haven't just meta-analysed the original studies of which there were four. They've gone back to the source data to the authors of those studies, pooled it all together in a harmonized manner. It doesn't have to be fancy statistics to impute the missing variables and then done their analysis.
What they've also done is quite a comprehensive sensitivity analysis. So they've tested that hypothesis in three or four different ways and come up with the same answer each time. They've taken, it's just over 1,500 eligible patients, about 65% complete data, which gives them just over a thousand patients, which is a huge patient group if you look at the spinal cord injury literature. And effectively what they've shown is if you operate, that is to say decompress and or stabilize if you need to before [00:02:00] 24 hours, your odds ratio of an improved ASIA score at one year is about 1.48. So it is quite a significant chance of improving neurological outcome in a year.
I think it's a really clear message. It's a well-written paper and I think it really is, it's quite a big stick with which to go to our theatre teams, go to our radiology department and say look, we need to be doing this now. This is now the model standard of care. They've obviously picked 24 hours as a cutoff based on sort of historical benchmarks. But the implication, I think, seems to be that bringing that forwards even further may well improve outcomes further. Do you think there's going to be a cutoff point at which point you sort of get a good plateau at the shortest end of the spectrum?
Yeah, it's hard to know. And this study doesn't have enough numbers in the very early phase to determine between let's say eight and 24 hours. But certainly I agree there's a hint that the sooner you get to these patients, like we used to with the compartment syndromes, you know, back 10 years ago or so. I think there's going to be a shift towards [00:03:00] earlier is better and I think what we'll find is between eight and 12 hours is going to be even better than kind of 24 hours.
What we can see from the data here is that after 24 hours, you start to see a more significant decline in neurological function. But 36 hours really there's no benefit to operating then or a week later. But if I had to hedge my bets, it would be sooner is better.
It's going to take some pretty significant logistical shifts in how we have access to scanning and theatre on the ground isn't it?
Yeah, that's right. I mean, one thing, interestingly, this paper doesn't talk about is the role of MRI scanning in the acute phase and so on, which obviously for our trauma teams who have quite a well-developed system now, you know, CT has become absolutely integral to early care. That's going to be a change. You know, we've got unstable patients with a lot of equipment attached to them and so on and leaving them on their own for 40 minutes in the MR scanner is going to be a risk. But I think I know that the group is working on similar work, looking at the [00:04:00] role of MR in the early phase. And I think that's going to be part of the sort of 21st century spinal cord injury care.
That's fantastic. So what's your thoughts on the next step in terms of looking into this from a research perspective?
There's two arms to this, what we need to do is know what do we need in order to make the right surgical decision in that very acute phase in cord injury? That might be MR, it might be, you know, more detailed neurological assessment or something like that. And the second part is, as you say, we've said 24 hours for now, does eight hours make a difference? Does six hours make a difference?
And I think that's the next phase here is to really know where we need to strike with these difficult to manage patients.
So thank you to Brett for that really interesting article. And now we're gonna move on to the roundups from this month's journal.
So first starting with hip and pelvis. Our first paper from the USA looks at the medial plating for Pauwels type III femoral neck fractures. These vertical fractures [00:05:00] are often seen in younger high energy trauma patients and complications in this group are high with reoperation rates of around 20%, non-union rates are 15% and avascular necrosis as high as 10%. Pauwels III configuration increases varus and sheer forces. A sliding hip screw construct is probably better than cannulated hip screws as it is angular stable, but adding a canulated hip screw to a sliding hip screw is better again, probably by reducing sheer and rotational forces.
This paper asks is a medial calcar plate, a better augment than a fully threaded cannulated screw when used with a 135 degrees sliding hip screw. Ten matched cadaveric pairs were tested and found that in almost all cases, the medial plate showed improved stability. It doesn't make it any easier to insert the plate in a real patient however.
Our second paper from China is a [00:06:00] systematic review and meta-analysis comparing arthoplasty and internal fixation for displaced femoral neck fractures in the elderly. The two options have different risk profiles. 31 randomized control trials were included and arthroplasty in internal fixation didnt seem to have a significant difference at short- or long-term followup.
However, arthroplasty was much less likely to cause complications with a relative risk of 0.3 in the long-term, and was also associated with lower postoperative pain with a relative risk of 0.5. In addition, a trial sequential analysis indicates that there is more than enough evidence of these findings.
Sticking with the theme of hip fractures, our final hip and pelvis paper from South Korea considers the use of dual mobility total hip arthroplasty for patients with femoral neck fractures. The current choice of hemiarthroplasty and conventional [00:07:00] total hip replacement presents a difficult trade-off between small gains in function and small increases in complications, particularly that of dislocation. Can the dual mobility design solve this problem? According to this systematic review and meta analysis of 17 papers with 2,263 hips comparing bipolar hemiarthroplasty and dual mobility designs, the answer is yes, with lower dislocation rates and one year mortality rates.
A word of caution however, this study included non-randomized control trials so one has to wonder if the better mortality rates actually reflect a healthier population in the dual mobility group.
So onto our Knee Roundup, our first paper from the UK looks at the effect of antibiotic loaded bone cement on the risk of revision, following hip and knee arthroplasty. Infection in the presence of a joint [00:08:00] replacement is a difficult clinical problem for both patient and surgeon and prevention is certainly better than cure. While antibiotic cement is prevalent in the UK, it is less so across the pond in the USA. This massive meta-analysis includes over 650,000 total knee replacements. There was no significant differences in revision rates for prosthetic joint infection or all causes with or without antibiotics. The study also included over 350,000 total hip replacements. And in this case the use of antibiotic cement did reduce the risk of infected revision with a relative risk of 0.66.
Our second paper from New Zealand reports on 230 infected total knee arthroplasties in a 15 year multicentre retrospective cohort review. The aim was to establish the success rate of debridement [00:09:00] antibiotics and implant retention, or DAIR. One of the difficulties is that it is often not clear until years later if a cure or a suppression has been achieved. The strength of this paper is in its mean follow-up of 6.9 years. With an overall success rate of 53.9%. The results suggest that DAIR can be used as an equally successful strategy up to a year following implantation.DAIR was successful in 64% of early infections within a year of implantation, but only 38% after a year. The presence of staphylococcus aureus and gram negative infections were risk factors for failure.
Our final paper from Singapore looks at the coronal alignment of unicompartmental knee replacements. It included 264 knees with data on PROMS and survivorship. A tibial coronal angle of two to [00:10:00] four degrees and femoral coronal angle of zero to two degrees conferred 100% 15 year survival versus 92% when prosthesis fell outside of these ranges. It is worth noting these data were collected on fixed bearing cemented unicompartmental knee arthoplasties. So the take home message is target two degrees.
Moving onto sports our first paper from South Korea looks at the controversial topic of PRP injections in the context of rotator cuff disease. 60 patients with symptomatic cuff disease were randomized to allergenic PRP injection or local anesthetic and steroid. There was no control group and all patients received concurrent physiotherapy. At six months no significant differences were found between the groups on PROMS or clinical assessment.
Our second paper from [00:11:00] Finland looks at arthroscopic subacromial decompression, another thorny subject. 210 patients between the ages of 35 and 65 with symptoms consistent with subacromial impingement for longer than three months were randomized to arthroscopic subacromial decompression or diagnostic arthroscopy and followed up for a minimum of five years. An impressive 83% completed followup and no clinically important difference in outcomes was found between the groups.
Our final sports paper from the USA asks if ACL reconstruction changes gait biometrics five years after surgery. This only looked at patients with isolated ACL injuries in athletes, 40 of whom were treated operatively and 17 non-operatively. Patients treated non-operatively had greater medial compartment contact forces and peak knee adduction [00:12:00] moments. While over the time period of this study this did not result in any radiological differences, it does add weight to the view that over longer periods, knees without reconstruction are at higher risk of post-traumatic arthritis. It also aligns with patient-reported complaints that the need just doesn't feel right until after reconstruction.
Next foot and ankle. Our first foot and ankle paper from the USA looks at the complication rates and outcomes for first metatarsal phalangeal joint arthrodesis for hallux rigidus in patients over the age of 65, compared to younger patients. 143 patients were followed up for three years with 64 patients over the age of 65 included.
Both groups of patients benefited equally on patient-reported outcomes. And the complication rates were the same in both groups. The results are worth considering [00:13:00] when discussing surgical options with patients in this age group.
Our next paper also from the USA looks at the ever-present problem of the syndesmosis or more accurately it's reduction after trauma. This anatomy paper looked at 213 bilateral CT scans taken for other reasons, such as measurement of lower limb rotational alignment. It is worth noting that all CT scans were taken non-weightbearing, which must be considered in interpreting the results. More than one-third of patients had at least one radiological parameter outside of the currently defined normal limits.This therefore raises the question what truly is normal. And can we compare side to side or like for like in decision-making in theater, our final foot and ankle paper from the UK asks if the anatomical access of the tibia is good enough to assess the tibio tailor [00:14:00] alignment. When planning, we constructive procedures of the ankle and hind foot.
The study investigated with a coronal tibio Taylor alignment using the mechanical axis of the limb would differ from alignment, measured using the anatomical access of the tibia in patients with symptomatic ankle arthritis who were waiting for ankle arthroplasty, 61 weight-bearing long leg. And Turo pasty area radiographs were used to measure the mechanical axis of the limb mechanical axis of the tibia, the anatomical axis of the tibia.
And we're compared to a line along the Taylor articular surface. It shows that tibio Taylor alignment. Should be based on the mechanical axis of the tibia. Since in a surprisingly high proportion of patients, discrepancies may arise affecting long-term outcomes of realignment procedures. This is a good read for those preparing for the FRCs.
So moving on to wrist [00:15:00] and hand. Our first wrist and hand paper from the USA looks at chronic pain. One year after operative management of distal radius fractures. This was a secondary analysis of data produced by the prospective wrist and radius injury surgical trial. The initial trial randomized. Those over 60 years of age with extra articular distal radius fractures to closed reduction and percutaneous pending external fixation or open reduction and internal fixation chronic pain was defined as anything above zero on the pain domain of the Michigan hand outcomes questionnaire, which is scored out of 100 on this metric pain was present at one year in.
59.6% of patients, time to surgery have less than one week and open reduction. Internal fixation both seem to significantly reduce chronic pain at one year, which is a very interesting finding. [00:16:00] However, pain has been dichotomized to present or absent and not quantified. And we do not know how many patients had clinically important pain.
Our second paper from the UK. Looks at venous thromboembolic events in hand surgery events were included if they occurred within 90 days of surgery. National data for a two year period were studied and an impressive 71,000 trauma cases were included were no cases of DVT. And one PE were recorded 260,000 elective cases recorded 13 DV Ts.
And 26 PEs, no events were recorded in patients with no identified risk factors and no temporal relationship between those events, which did occur. And surgery was found the rate of VTE events following and attributable to hand surgery seems likely. To [00:17:00] be very small, our final rest and hand paper also from the UK performs a cost utility analysis of open a one poly release for the treatment of trigger finger.
The condition effects. 2% of us, at some point in our lives, 192 patients were included in the analysis and after failing initial management was steroid injection on the assumption that the benefit of release was maintained for two years. Post-operatively a quality, a quality adjusted life year. At two years of 16,154 pounds showed that open trigger finger release was cost-effective.
Next shoulder and elbow. Our first paper is from Australia and is a small double-blind randomized control trial of 60 patients undergoing anatomic or reverse total shoulder replacement, assessing blood loss with or without tranexamic acid. Two grams [00:18:00] of tranexamic acid were given at induction and all patients received a surgical drain at 24 hours.
The tranexamic acid group had 94 mils of total blood loss compared to 226 mils for the group who did not receive it. However, no significant difference in secondary outcomes, such as length of stay postoperative pain were identified. This is a small study on elective patients, and it would be interesting to see a similar study in trauma patients.
It seems reasonable on the basis of this study to support the use of tranexamic acid for shoulder arthroplasty. Our second study from the USA looks at the role of non-operative management of massive, a repairable rotator cuff tears. It is a systematic review and meta analysis of 10 studies. The majority of which were level four data.
The overall success rate ranged from 32% or [00:19:00] 96% with significant improvements in functional outcomes schools. Range of movement and strength. The study went on to suggest a treatment protocol for this patient group, including supervised physiotherapy for greater than three months. Anti-inflammatory medications and steroid injections.
Clearly the quality of the evidence going into the Metro analysis was not ideal, but this does add to the growing body of evidence that surgery should be reserved for refractory or specific cases. Our final shoulder and elbow paper also from the USA seeks to identify an interscalene block regime in patients undergoing arthroscopic, rotator, cuff repair, with a view to reducing postoperative opioid use.
The design was a three arm, double blind randomized control trial. The control was bupivacaine and dexamethazone and the two interventions were liposomal bupivacaine plus NORML bupivacaine and [00:20:00] lyposomal bupivacaine and dexamethazone lyposomal bupivacaine has a longer duration of action. Both intervention groups, shades significantly lower post-operative narcotic use.
This is a small study, but the findings are important and future research should be directed at you. Cost analysis, say moving on to spine. Our first buying paper comes from the Netherlands and it's a Metro analysis of randomized control trials that investigate the effectiveness of surgery for patients with cervical radiculopathy without myelopathy 21 randomized control trials with 1,567 patients were included.
Clinical outcomes were equivalent among all the studied surgical interventions complication, and we operation rates were also similar with the exception of operations using autologous bone grafts, where higher complication rates were [00:21:00] reported on the basis of this data. There is no evidence to support one surgical intervention over another for this group of patients.
I find the spine paper from New Zealand seeks to identify predictors of failure for non-operative management of spinal epidural abscess. Interestingly, the classical triad of symptoms was only seen in 7% of patients back pain was present in 65%, 77% had a fever and 43% neurological symptoms. Blood cultures were positive in 76% and the causative organism was staphylococcus Orpheus in 58% significant predictors of failure.
Of non-operative management, where multifocals, sepsis marry ethnicity and a high white cell count overall 36% would be expected to fail non-operative management, [00:22:00] moving on to our bumper crop of trauma papers. Our first of four trauma papers is from the USA and this informs the difficult clinical decision-making for patients presenting with fractures of the greater trochanter.
When we see an x-ray of an isolated greater decanter fracture, most patients will go on to have a subsequent CT or MRI to look for extension. This retrospective series of 17 patients showed that MRI confirmed intertrochanteric extension in all patients, the extension, however, was less than 50% in all, but one patient and none of the patients required operative intervention over the period of followup.
This is reassuring to those of us considering pursuing a course of non-operative management. Staying with hip fractures. This paper from the UK gives some insight into the outcomes of non-operative management in overburdened healthcare services stretched to breaking point [00:23:00] by COVID. This has been a reality over the last year for some this Metro analysis of 25 page papers included 2,615 patients.
The reasons for non-operative management were predominantly due to the patient being deemed unfit for surgery, and the results must be viewed through this lens. 30 day, mortality was 36% and one year mortality, 60%. However impatience mobilized early mortality fell to 20% at six months. If non-operative management is a necessity, either due to patient factors or resource deficiency, the interventions which can improve outcomes are adequate analgesia and blocks early mobilization and prompt, discharged from the acute setting.
Our next paper from Finland looks at the issue of humoral bracing for closed displaced fractures. It is a [00:24:00] small randomized control trial, including ATG patients, randomized to open reduction and internal fixation or functional bracing with a primary outcome of the dash score at 12 months. No clinically important difference was found on the dash score.
However, 30% of patients randomized to functional brace crossed over to open reduction and internal fixation, mainly due to delayed or nonunion in the period of study. 8% of those randomized to surgery developed a temporary radial nerve palsy. This study doesn't have the power to inform which treatment should be used.
If the aim is to avoid non-union. It results are useful in informing discussion with patients when deciding on a treatment, uh, final paper from the UK looks at the effects of screening for NRSA and common sense staff initiatives to encourage hand-washing as a means to reduce [00:25:00] surgical site infection.
In hip fracture patients a longer toodle cohort study with data interrogated by auto regressive integrated moving average time series analysis reviewed 7,314 patients before MRI say screening and 6,189 after. Screening did reduce MRI, say surgical site infection, but hand hygiene initiatives did not.
Over the 17 years of the study, the overall surgical site infection rate fell from 2.4% to 1.5%. I think this data emphasizes the importance of surveillance and evaluation of infection control. As prevention remains better than cure. So next on cology, our first oncology paper from the USA asks if we need to follow up or workup incidental long [00:26:00] bone cartilage lesions, 73 patients were followed up for a mean duration of 47 months.
Ultimately 15% turned out to have condray sarcomas. Which were identified subsequent to the incidental finding all chondrocyte came, a patients developed pain and aggressive imaging findings. Therefore the rate of chondrosarcoma in incidentally found lesions, which do not develop aggressive features and remain painless is very low.
Further. Imaging may only really be needed when new symptoms develop our final oncology study from Singapore reviewed every patient nationally who underwent joint preservation surgery for treatment of orthopedic oncological diseases. Between 1978 and 2008 for both health and satisfaction, 256 survivors were identified of whom 162 [00:27:00] were available for study.
The main follow-up was 9.1 years. This data found that amputations were equally as satisfactory as after DCIS and arthoplasty surgery, but the joint salvage was superior to all of the others. The three interventions say moving on to children's orthopedics. Our first pediatric paper comes from Ireland and examines.
The feasibility of day-case pelvic osteotomies, 84 consecutive patients were operated on over the study period and 35 met the inclusion criteria for day K surgery. For these patients, 70 inpatient bed days were saved with a cost saving of over 100,000 euros. Over the course of the study, a specific intraoperative and postoperative analgesic regime was used and detailed patient information was given with backup from a nurse led telephone.
[00:28:00] Follow-up. Three patients shed Jord for day-case treatment remained in hospital and four patients returned on the second post-operative day due to inadequate pain control. This study does demonstrate the feasibility of day-case or indeed short-stay surgery for what can be quite major surgery in pediatric patients and demonstrates the inherent financial benefits of this.
Our second paper from the USA looks at the characteristics and reoperation rates of pediatric tarsal coalitions. This paper is unusual in that the focus was on long-term followup with a median of 14.4 years, over a 54 year period. 58 patients with 85 coalitions were identified from a County database.
46 were Cal Kamia, navicular 30 Taylor calcaneal and the remaining nine were mainly tailored. Evacuate 46 were treated [00:29:00] with Arthur DCIS or resection. And 39 were treated non-operatively the overall reoperation rate for those treated surgically was 8.7% with no significant risk factors found the surgical group did report fewer persistent symptoms at final followup with 33% versus 67%.
For those treated non-operatively our final pediatric paper also from the USA asks if post cast removal x-rays. And a second followup appointment are necessary when treating non-displaced supracondylar humeral fractures 489 patients were included in a single center, eight year review, all but two patients had routine radiographs after cast removal and no patient had their management changed as a result of this x-ray.
After the cast was removed 290 of these patients returned for a further outpatient [00:30:00] appointment, primarily to check their range of movement had returned to normal. 95% of these patients were discharged at this point with no change to management. And the vast majority of the remaining 5% simply had a further follow-up appointment arranged to continue to check progress while follow-up imaging and appointments may be reassuring in an increasingly financially pressured time.
They look more like a luxury on the basis of this data. A simple wellbeing core could replace followup and likely safely identify the one in 20 patients who may need review for stiffness. I'm fine. I final Roundup of this podcast is research. Our first paper from China looks at the performance of promising novel sinoatrial biomarkers for detecting Perry prosthetic joint infection in the presence of inflammatory joint disease.
50 synovial fluid [00:31:00] samples were taken from patients with and without prosthetic joint infection and were compared to 22 samples in patients with active, inflammatory joint disease, bactericidal, permeability, increasing protein. Lactoferrin. Neutrophil gelatinize associated lipase calcine neutrophil elastase two and alpha defensin were all found to be useful in diagnosing prosthetic joint infection, but all had the potential to be misleading in the presence of inflammatory joint disease.
For this subgroup of patients, it is likely that higher thresholds are needed for diagnosis, but what those thresholds are remains to be uncovered a second paper from China, looks at the possibility of an association between type two diabetes and osteoarthritis in adults over the age of 50. And analysis of 7,781 [00:32:00] patients was carried out and why they significant positive association was identified.
This disappeared. Once BMI was controlled for it is possible that there is a complex relationship present, but no causal relationship can be suggested on the base of this data. And our final research paper from the USA looks at patients in the sixth decade of life with an undisplaced or stable hip fracture.
The team retrospectively analyzed the Hounsfield unit measurements in 114 patients who underwent surgical fixation of intracapsular femoral, neck fractures. The investigators found that the Hinesville unit measurements of the femoral head was significantly associated with screw penetration and femoral neck shortening, but not revision surgery, CT scan Hansfield unit measurements in the femoral head and neck.
May therefore be useful in deciding whether to treat a nondisplaced femoral neck fracture [00:33:00] with internal fixation or after blasty. I hope you've enjoyed this month's podcasts. Have a look at the full journal to read our roundups or many more interesting papers and to get the references for the papers we've discussed today.
I look forward to seeing you for our next podcast later this month.