Pub Date : 2019-12-05DOI: 10.1097/CORR.0000000000001072
J. Rickert
Despite well-known concerns over its efficacy [12, 13], arthroscopic partial meniscectomy (APM) continues to be one of the most commonly performed orthopaedic procedures in the United States [5]. How can that be? I believe that because of the relative infrequency of adverse events related to APM, the orthopaedic community and our referring physicians view APM as a “bread-and-butter” operation that is a generally safe (and quick) procedure. Additionally, as noted in a recent Clinical Faceoff on this very topic [9], it is easy for an individual surgeon to believe that the evidence does not apply to his or her patients or our results—our patients are somehow different. But two recent studies [1, 4] sound the alarm on the serious longterm risks of APM and compel us to curtail its use in patients with arthritic knees as doing so may, in fact, worsen their health. The first of these studies found that patients who underwent APM and were followed for at least 15 years were 10 times more likely to proceed with a knee arthroplasty compared to the general population [1]. The length of this study’s follow-up, and its vast size (nearly 1 million patients) were compelling, as were a number of its other findings, such as the authors’ observation that patients with a history of APM in only one knee, the risk of knee arthroplasty was three times greater than in their knee without a history of APM. The findings of that enormous observational study [1] were substantially supported by a recent, large randomized trial that arrived at substantially the same conclusion [4]. Those authors found that patients treated with knee arthroscopy for meniscal tears in an arthritic joint were almost five times more likely to proceed to total knee replacement (while achieving no better pain relief) compared to those treated non-operatively [4]. Therefore, the most-obvious, and, indeed, quite alarming, conclusion from these studies is that the use of APM in patients with arthritic knees makes it more likely that they will undergo subsequent knee replacement. While total knee replacement is an excellent option for many patients whose symptoms persist despite reasonable non-surgical treatments, the operation carries well-known lifeand limb-threatening risks of its own [2]. It is wrong to use a procedure like APM that does not alleviate symptoms [3], but increases the chance that our patients will undergo even larger surgery later in the form of a knee replacement [1, 4]. Too many APMs are being done, and the evidence is clear that this is bad for our patients [1, 4, 11]. Surgeons must change this harmful practice A note from the Editor-in-Chief: We are pleased to present our next installment of “On Patient Safety.” Dr. Rickert is on the clinical faculty at Indiana University School of Medicine and serves as President of The Society for Patient Centered Orthopedics. The goal of this quarterly column is to explore the relationships among patient safety, value, and clinical efficacy by
尽管对其疗效存在众所周知的担忧[12,13]，但关节镜半月板部分切除术(APM)仍然是美国最常用的骨科手术之一[5]。这怎么可能呢?我认为，由于与APM相关的不良事件相对较少，骨科社区和我们的转诊医生将APM视为“面包和黄油”手术，通常是安全(和快速)的手术。此外，正如最近关于这一主题的临床对峙中所指出的[9]，单个外科医生很容易认为这些证据不适用于他或她的患者或我们的结果——我们的患者在某种程度上是不同的。但最近的两项研究[1,4]对APM的严重长期风险敲响了警钟，并迫使我们减少对膝关节关节炎患者的使用，因为这样做实际上可能会使他们的健康状况恶化。第一项研究发现，与普通人群相比，接受APM并随访至少15年的患者进行膝关节置换术的可能性要高10倍[1]。这项研究的随访时间之长、规模之大(近100万患者)令人信服，其其他一些发现也令人信服，比如作者观察到，只有一个膝盖有APM病史的患者，膝关节置换术的风险是没有APM病史的患者的三倍。这项庞大的观察性研究[1]的发现得到了最近一项大型随机试验的有力支持，该试验得出了基本相同的结论[4]。这些作者发现，与非手术治疗的患者相比，通过膝关节镜治疗关节炎关节半月板撕裂的患者进行全膝关节置换术的可能性几乎是其5倍(同时没有更好的疼痛缓解)[4]。因此，从这些研究中得出的最明显的，实际上也是相当令人担忧的结论是，在膝关节关节炎患者中使用APM更有可能使他们接受后续的膝关节置换术。虽然对于许多经过合理的非手术治疗后症状仍然存在的患者来说，全膝关节置换术是一个很好的选择，但众所周知，该手术本身存在危及生命和肢体的风险[2]。使用像APM这样不能缓解症状的手术是错误的[3]，但会增加我们的患者以后需要进行更大的膝关节置换术的机会[1,4]。我们做了太多的apm，证据清楚地表明这对我们的病人是有害的[1,4,11]。外科医生必须改变这种有害的做法。总编辑的注释:我们很高兴地介绍我们的下一期“患者安全”。Rickert博士是印第安纳大学医学院的临床教师，并担任the Society for Patient Centered Orthopedics的主席。本季度专栏的目标是通过参与不同的观点，包括骨科医生、患者、消费者和患者倡导者以及医疗保险公司，探索患者安全、价值和临床疗效之间的关系。我们欢迎读者对我们所有的专栏和文章进行反馈;请将您的意见发送至eic@clinorthop.org。提交人证明，他本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股票所有权、股权、专利/许可安排等)。本文仅代表作者个人观点，不代表CORR或骨关节外科医师协会的观点或政策。J. Rickert MD (MD)，印第安纳大学健康中心南印第安纳内科医生，Clarizz大道583号。，美国印第安纳州布卢明顿47401，电子邮件:jrickert1@iuhealth.org
{"title":"On Patient Safety: Orthopaedic Surgeons Must Stop Performing Arthroscopic Partial Meniscectomy on Patients with Arthritic Knees.","authors":"J. Rickert","doi":"10.1097/CORR.0000000000001072","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001072","url":null,"abstract":"Despite well-known concerns over its efficacy [12, 13], arthroscopic partial meniscectomy (APM) continues to be one of the most commonly performed orthopaedic procedures in the United States [5]. How can that be? I believe that because of the relative infrequency of adverse events related to APM, the orthopaedic community and our referring physicians view APM as a “bread-and-butter” operation that is a generally safe (and quick) procedure. Additionally, as noted in a recent Clinical Faceoff on this very topic [9], it is easy for an individual surgeon to believe that the evidence does not apply to his or her patients or our results—our patients are somehow different. But two recent studies [1, 4] sound the alarm on the serious longterm risks of APM and compel us to curtail its use in patients with arthritic knees as doing so may, in fact, worsen their health. The first of these studies found that patients who underwent APM and were followed for at least 15 years were 10 times more likely to proceed with a knee arthroplasty compared to the general population [1]. The length of this study’s follow-up, and its vast size (nearly 1 million patients) were compelling, as were a number of its other findings, such as the authors’ observation that patients with a history of APM in only one knee, the risk of knee arthroplasty was three times greater than in their knee without a history of APM. The findings of that enormous observational study [1] were substantially supported by a recent, large randomized trial that arrived at substantially the same conclusion [4]. Those authors found that patients treated with knee arthroscopy for meniscal tears in an arthritic joint were almost five times more likely to proceed to total knee replacement (while achieving no better pain relief) compared to those treated non-operatively [4]. Therefore, the most-obvious, and, indeed, quite alarming, conclusion from these studies is that the use of APM in patients with arthritic knees makes it more likely that they will undergo subsequent knee replacement. While total knee replacement is an excellent option for many patients whose symptoms persist despite reasonable non-surgical treatments, the operation carries well-known lifeand limb-threatening risks of its own [2]. It is wrong to use a procedure like APM that does not alleviate symptoms [3], but increases the chance that our patients will undergo even larger surgery later in the form of a knee replacement [1, 4]. Too many APMs are being done, and the evidence is clear that this is bad for our patients [1, 4, 11]. Surgeons must change this harmful practice A note from the Editor-in-Chief: We are pleased to present our next installment of “On Patient Safety.” Dr. Rickert is on the clinical faculty at Indiana University School of Medicine and serves as President of The Society for Patient Centered Orthopedics. The goal of this quarterly column is to explore the relationships among patient safety, value, and clinical efficacy by","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"4 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85087314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-03DOI: 10.1097/CORR.0000000000001050
M. Grecula
Taking blood conservation measures for patients undergoing TKA is important because blood transfusions after surgery can increase the risk of serious complications, including prosthetic joint infection and death. Post-operative anemia also is associated with prolonged hospital stay and delayed rehabilitation; these risks are especially severe in patients with other comorbidities [18]. The best current evidence now favors use of tranexamic acid (TXA) [5]. This drug has been a game-changer for arthroplasty patients who previously had been treated with a host of interventions to try to mitigate blood loss and reduce transfusion after TKA, including preoperative autologous blood donation, pre-operative stimulation of erythropoiesis, controlled hypotension, hemodilution, intra-operative or post-operative blood salvage, tourniquet use and timing of deflation, thermal energy, fibrin spray, peri-articular injections, continuous passive motion versus splinting, intra-operative and post-operative knee positioning, and cryotherapy [9, 10]. Introduced in 1962 as a treatment to reduce the severity of post-partum hemorrhage [20], TXA was first approved by the US Food and Drug Administration in 1986 to reduce bleeding in patients with hemophilia undergoing tooth extraction [4]. Despite increasing evidence supporting TXA use in multiple medical disciplines, and its inclusion on the World Health Organization’s list of essential medicines [21], the FDA has only expanded its use to include treating heavy cyclic menstrual bleeding [11]. Despite the fact that any use of TXA in patients undergoing TKA is considered offlabel by the FDA, its use in TKA now is widespread and well supported by randomized trials [6, 12, 17] and numerous meta-analyses [3, 8, 22, 23]. Being an anti-fibrinolytic, TXA has the theoretical risk of harmful vascular thrombosis, and thus empirically, caution has been used in orthopedic studies by excluding patients with previous history (or increased risk) of thromboembolic events, including patients who have had or are at risk for deep vein thrombosis/pulmonary embolism, stroke, myocardial infarction, history of cardiac stents or bypass surgery, or who have thrombophilia [12, 17]. However, these theoretical risks have not been confirmed in multiple large studies [13]. The current randomized, doubleblind trial by Meshram and colleagues [14] found no “clinically significant difference” in both the primary and secondary outcome variables between the IA only and combined IA and IV groups in both the simultaneous and This CORR Insights is a commentary on the article “Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial” by Meshram and colleagues available at: DOI: 10. 1097/CORR.0000000000000942. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, s
对TKA患者采取血液保护措施很重要，因为术后输血会增加严重并发症的风险，包括假体关节感染和死亡。术后贫血也与住院时间延长和康复延迟有关;这些风险在有其他合并症的患者中尤为严重。目前最好的证据支持使用氨甲环酸(TXA)[5]。这种药物改变了关节置换术患者的游戏规则，这些患者之前接受了一系列干预措施，试图减轻TKA后的失血和输血，包括术前自体献血，术前刺激红细胞生成，控制低血压，血液稀释，术中或术后血液回收，止血带的使用和放空时间，热能，纤维蛋白喷雾，关节周围注射，持续被动运动与夹板、术中及术后膝关节定位和冷冻治疗的对比[9,10]。TXA于1962年作为一种减轻产后出血严重程度的治疗方法被引入，1986年首次被美国食品和药物管理局批准用于减少血友病患者拔牙时出血。尽管越来越多的证据支持TXA在多个医学领域的使用，并且它被列入世界卫生组织的基本药物清单，FDA只扩大了它的使用范围，包括治疗重度月经周期出血。尽管事实上，在接受TKA的患者中使用TXA被FDA认为是标签外的，但它在TKA中的使用现在是广泛的，并且得到了随机试验[6,12,17]和大量荟萃分析[3,8,22,23]的充分支持。作为一种抗纤溶药物，TXA具有有害血管血栓形成的理论风险，因此在骨科研究中，谨慎排除有血栓栓塞事件史(或风险增加)的患者，包括有或有深静脉血栓/肺栓塞、中风、心肌梗死、心脏支架或搭桥手术史或有血栓倾向的患者[12,17]。然而，这些理论上的风险尚未在多个大型研究中得到证实。目前由Meshram及其同事[14]进行的随机双盲试验发现，在同时使用IA组和联合IA和IV组之间，主要和次要结局变量没有“临床显著差异”。这篇CORR Insights是对“联合静脉注射和关节内注射氨甲环酸与单独关节内使用相比，在双侧TKA中没有额外的益处”一文中的评论:Meshram及其同事的《随机对照试验》可在:DOI: 10。1097 / CORR.0000000000000942。提交人证明，他本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股票所有权、股权、专利/许可安排等)。所表达的观点是作者的观点，不反映CORR或骨关节外科医生协会的观点或政策。M. J. greula MD (MD)，美国德克萨斯大学医学院骨科康复科，301 University Blvd。， 0165号公路，加尔维斯顿，得克萨斯州77555美国，电子邮件:mgrecula@utmb.edu
{"title":"CORR Insights®: Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial.","authors":"M. Grecula","doi":"10.1097/CORR.0000000000001050","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001050","url":null,"abstract":"Taking blood conservation measures for patients undergoing TKA is important because blood transfusions after surgery can increase the risk of serious complications, including prosthetic joint infection and death. Post-operative anemia also is associated with prolonged hospital stay and delayed rehabilitation; these risks are especially severe in patients with other comorbidities [18]. The best current evidence now favors use of tranexamic acid (TXA) [5]. This drug has been a game-changer for arthroplasty patients who previously had been treated with a host of interventions to try to mitigate blood loss and reduce transfusion after TKA, including preoperative autologous blood donation, pre-operative stimulation of erythropoiesis, controlled hypotension, hemodilution, intra-operative or post-operative blood salvage, tourniquet use and timing of deflation, thermal energy, fibrin spray, peri-articular injections, continuous passive motion versus splinting, intra-operative and post-operative knee positioning, and cryotherapy [9, 10]. Introduced in 1962 as a treatment to reduce the severity of post-partum hemorrhage [20], TXA was first approved by the US Food and Drug Administration in 1986 to reduce bleeding in patients with hemophilia undergoing tooth extraction [4]. Despite increasing evidence supporting TXA use in multiple medical disciplines, and its inclusion on the World Health Organization’s list of essential medicines [21], the FDA has only expanded its use to include treating heavy cyclic menstrual bleeding [11]. Despite the fact that any use of TXA in patients undergoing TKA is considered offlabel by the FDA, its use in TKA now is widespread and well supported by randomized trials [6, 12, 17] and numerous meta-analyses [3, 8, 22, 23]. Being an anti-fibrinolytic, TXA has the theoretical risk of harmful vascular thrombosis, and thus empirically, caution has been used in orthopedic studies by excluding patients with previous history (or increased risk) of thromboembolic events, including patients who have had or are at risk for deep vein thrombosis/pulmonary embolism, stroke, myocardial infarction, history of cardiac stents or bypass surgery, or who have thrombophilia [12, 17]. However, these theoretical risks have not been confirmed in multiple large studies [13]. The current randomized, doubleblind trial by Meshram and colleagues [14] found no “clinically significant difference” in both the primary and secondary outcome variables between the IA only and combined IA and IV groups in both the simultaneous and This CORR Insights is a commentary on the article “Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial” by Meshram and colleagues available at: DOI: 10. 1097/CORR.0000000000000942. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, s","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"38 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78821012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-03DOI: 10.1097/CORR.0000000000001067
A. Burssens, K. Buedts, A. Barg, E. Vluggen, P. Demey, C. Saltzman, J. Victor
BACKGROUND The goals of lower limb reconstruction are to restore alignment, to improve function, and to reduce pain. However, it remains unclear whether alignment of the lower limb and hindfoot are associated because an accurate assessment of hindfoot deformities has been limited by superposition on plain radiography. Consequently, surgeons often overlook hindfoot deformity when planning orthopaedic procedures of the lower limb. Therefore, we used weight-bearing CT to quantify hindfoot deformity related to lower limb alignment in the coronal plane. QUESTIONS/PURPOSES (1) Is lower-limb alignment different in varus than in valgus hindfoot deformities for patients with and without tibiotalar joint osteoarthritis? (2) Does a hindfoot deformity correlate with lower-limb alignment in patients with and without tibiotalar joint osteoarthritis? (3) Is joint line orientation different in varus than in valgus hindfoot deformities for patients with tibiotalar joint osteoarthritis? (4) Does a hindfoot deformity correlate with joint line orientation in patients with tibiotalar joint osteoarthritis? METHODS Between January 2015 and December 2017, one foot and ankle surgeon obtained weightbearing CT scans as second-line imaging for 184 patients with ankle and hindfoot disorders. In 69% (127 of 184 patients) of this cohort, a combined weightbearing CT and full-leg radiograph was performed when symptomatic hindfoot deformities were present. Of those, 85% (109 of 127 patients) with a median (range) age of 53 years (23 to 75) were confirmed eligible based on the inclusion and exclusion criteria of this retrospective comparative study. The Takakura classification was used to divide the cohort into patients with (n = 74) and without (n = 35) osteoarthritis of the tibiotalar joint. Lower-limb measurements, obtained from the full-leg radiographs, consisted of the mechanical tibiofemoral angle, mechanical tibia angle, and proximal tibial joint line angle. Weightbearing CT images were used to determine the hindfoot's alignment (mechanical hindfoot angle), the tibiotalar joint alignment (distal tibial joint line angle and talar tilt angle) and the subtalar joint alignment (subtalar vertical angle). These values were statistically assessed with an ANOVA and a pairwise comparison was subsequently performed with Tukey's adjustment. A linear regression analysis was performed using the Pearson correlation coefficient (r). A reliability analysis was performed using the intraclass correlation coefficient. RESULTS Lower limb alignment differed among patients with hindfoot deformity and among patients with or without tibiotalar joint osteoarthritis. In patients with tibiotalar joint osteoarthritis, we found knee valgus in presence of hindfoot varus deformity and knee varus in presence of hindfoot valgus deformity (mechanical tibiofemoral angle 0.3 ± 2.6° versus -1.8 ± 2.1°; p < 0.001; mechanical tibia angle -1.4 ± 2.2° versus -4.3 ± 1.9°; p < 0.001). Patients without tibiotal
{"title":"Is Lower-limb Alignment Associated with Hindfoot Deformity in the Coronal Plane? A Weightbearing CT Analysis.","authors":"A. Burssens, K. Buedts, A. Barg, E. Vluggen, P. Demey, C. Saltzman, J. Victor","doi":"10.1097/CORR.0000000000001067","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001067","url":null,"abstract":"BACKGROUND\u0000The goals of lower limb reconstruction are to restore alignment, to improve function, and to reduce pain. However, it remains unclear whether alignment of the lower limb and hindfoot are associated because an accurate assessment of hindfoot deformities has been limited by superposition on plain radiography. Consequently, surgeons often overlook hindfoot deformity when planning orthopaedic procedures of the lower limb. Therefore, we used weight-bearing CT to quantify hindfoot deformity related to lower limb alignment in the coronal plane.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Is lower-limb alignment different in varus than in valgus hindfoot deformities for patients with and without tibiotalar joint osteoarthritis? (2) Does a hindfoot deformity correlate with lower-limb alignment in patients with and without tibiotalar joint osteoarthritis? (3) Is joint line orientation different in varus than in valgus hindfoot deformities for patients with tibiotalar joint osteoarthritis? (4) Does a hindfoot deformity correlate with joint line orientation in patients with tibiotalar joint osteoarthritis?\u0000\u0000\u0000METHODS\u0000Between January 2015 and December 2017, one foot and ankle surgeon obtained weightbearing CT scans as second-line imaging for 184 patients with ankle and hindfoot disorders. In 69% (127 of 184 patients) of this cohort, a combined weightbearing CT and full-leg radiograph was performed when symptomatic hindfoot deformities were present. Of those, 85% (109 of 127 patients) with a median (range) age of 53 years (23 to 75) were confirmed eligible based on the inclusion and exclusion criteria of this retrospective comparative study. The Takakura classification was used to divide the cohort into patients with (n = 74) and without (n = 35) osteoarthritis of the tibiotalar joint. Lower-limb measurements, obtained from the full-leg radiographs, consisted of the mechanical tibiofemoral angle, mechanical tibia angle, and proximal tibial joint line angle. Weightbearing CT images were used to determine the hindfoot's alignment (mechanical hindfoot angle), the tibiotalar joint alignment (distal tibial joint line angle and talar tilt angle) and the subtalar joint alignment (subtalar vertical angle). These values were statistically assessed with an ANOVA and a pairwise comparison was subsequently performed with Tukey's adjustment. A linear regression analysis was performed using the Pearson correlation coefficient (r). A reliability analysis was performed using the intraclass correlation coefficient.\u0000\u0000\u0000RESULTS\u0000Lower limb alignment differed among patients with hindfoot deformity and among patients with or without tibiotalar joint osteoarthritis. In patients with tibiotalar joint osteoarthritis, we found knee valgus in presence of hindfoot varus deformity and knee varus in presence of hindfoot valgus deformity (mechanical tibiofemoral angle 0.3 ± 2.6° versus -1.8 ± 2.1°; p < 0.001; mechanical tibia angle -1.4 ± 2.2° versus -4.3 ± 1.9°; p < 0.001). Patients without tibiotal","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"35 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86205300","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/CORR.0000000000000836
Dominick V. Congiusta, Kamil M. Amer, A. Merchant, Michael M. Vosbikian, I. Ahmed
BACKGROUND Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate. QUESTIONS/PURPOSES (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time? METHODS A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios. RESULTS After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001). CONCLUSIONS We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or
{"title":"Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?","authors":"Dominick V. Congiusta, Kamil M. Amer, A. Merchant, Michael M. Vosbikian, I. Ahmed","doi":"10.1097/CORR.0000000000000836","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000836","url":null,"abstract":"BACKGROUND\u0000Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?\u0000\u0000\u0000METHODS\u0000A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.\u0000\u0000\u0000RESULTS\u0000After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).\u0000\u0000\u0000CONCLUSIONS\u0000We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82742715","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-01DOI: 10.1097/CORR.0000000000001018
F. Hornicek
{"title":"Giants of Orthopaedic Surgery: Henry J. Mankin MD.","authors":"F. Hornicek","doi":"10.1097/CORR.0000000000001018","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001018","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77806259","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-28DOI: 10.1097/CORR.0000000000001066
A. Abdeen
All arthroplasty surgeons have encountered a version of this rare-but-devastating situation: A patient returns for follow-up after TKA by a point in time when (s)he should be fully recovered. Examination reveals that the incision has healed well, ligaments are well-balanced, and radiographs show no evidence of malalignment, fracture, or loosening. But the patient reports substantial pain and says it “just doesn’t feel right”. Workup for infection is negative. The situation is upsetting for patient and surgeon alike. Although TKA is one of the most successful operations orthopaedic surgeons perform [14], persistent knee pain for unclear reasons occurs in as many as 8% to 34% of patients [4]. And while a number of patient factors, surgical technique elements, and implant factors may contribute [3, 8], our fundamental understanding of why some patients have this complication is sorely limited. Pain without objective clinical cause after TKA is the focus of awide range of clinical studies that point toward an equally broad array of possible etiologies [6]. Some studies suggest pain without objective etiologymay bemore common in black patients, women, young patients, and patients with lower educational achievement [6, 10, 11]. Other factors that may be associated with persistent pain following TKA include chronic pain remote to the operative knee, fibromyalgia, anxiety, substance use disorders, lack of physical activity in adulthood, and increased acute pain trajectory immediately following TKA [13, 16]. Even genetic polymorphisms are speculated to be associated with persistent post-surgical pain [16]. Widespread pain—a contemporary classification for a number of chronic pain syndromes—encompasses the more-commonly used term of fibromyalgia and includes a broader array of more-nuanced clinical symptoms [18]. The authors of the current study found women (but not men) with widespread pain were more likely not to improve after TKA than were women without widespread pain [17].
{"title":"CORR Insights®: Widespread Pain Is Associated with Increased Risk of No Clinical Improvement After TKA in Women.","authors":"A. Abdeen","doi":"10.1097/CORR.0000000000001066","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001066","url":null,"abstract":"All arthroplasty surgeons have encountered a version of this rare-but-devastating situation: A patient returns for follow-up after TKA by a point in time when (s)he should be fully recovered. Examination reveals that the incision has healed well, ligaments are well-balanced, and radiographs show no evidence of malalignment, fracture, or loosening. But the patient reports substantial pain and says it “just doesn’t feel right”. Workup for infection is negative. The situation is upsetting for patient and surgeon alike. Although TKA is one of the most successful operations orthopaedic surgeons perform [14], persistent knee pain for unclear reasons occurs in as many as 8% to 34% of patients [4]. And while a number of patient factors, surgical technique elements, and implant factors may contribute [3, 8], our fundamental understanding of why some patients have this complication is sorely limited. Pain without objective clinical cause after TKA is the focus of awide range of clinical studies that point toward an equally broad array of possible etiologies [6]. Some studies suggest pain without objective etiologymay bemore common in black patients, women, young patients, and patients with lower educational achievement [6, 10, 11]. Other factors that may be associated with persistent pain following TKA include chronic pain remote to the operative knee, fibromyalgia, anxiety, substance use disorders, lack of physical activity in adulthood, and increased acute pain trajectory immediately following TKA [13, 16]. Even genetic polymorphisms are speculated to be associated with persistent post-surgical pain [16]. Widespread pain—a contemporary classification for a number of chronic pain syndromes—encompasses the more-commonly used term of fibromyalgia and includes a broader array of more-nuanced clinical symptoms [18]. The authors of the current study found women (but not men) with widespread pain were more likely not to improve after TKA than were women without widespread pain [17].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"3 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82821704","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUND The management of severe and recalcitrant diabetic foot ulcers is challenging. Distraction osteogenesis is accompanied by vascularization and regeneration of the surrounding tissues. Longitudinal distraction of the proximal tibia stimulates increased and prolonged blood flow to the distal tibia. However, the effects of transverse distraction of the proximal tibia cortex on severe and recalcitrant diabetic foot ulcers are largely unknown. QUESTIONS/PURPOSES (1) Does tibial cortex transverse distraction increase healing and decrease major amputation and recurrence of severe and recalcitrant diabetic foot ulcers compared with routine management (which generally included débridement, revascularization, negative pressure wound therapy, local or free flaps, or skin grafts as indicated)? (2) Does neovascularization and perfusion increase at the foot after the procedure? (3) What are the complications of tibial cortex transverse distraction in patients with severe and recalcitrant diabetic foot ulcers? METHODS Between July 2014 and March 2017, we treated 136 patients with diabetes mellitus and University of Texas Grade 2B to 3D ulcers (wound penetrating to the tendon, capsule, bone, or joint with infection and/or ischemia). The patients had failed to respond to treatment for at least 6 months, and their ulcers had a mean ± SD area of 44 cm ± 10 cm. All 136 patients underwent tibial cortex transverse distraction (partial corticotomy of the upper tibia, which was in normal condition, followed by 4 weeks of transverse distraction medially then laterally). We compared these patients with the last 137 consecutive patients we treated with standard surgical treatment, consisting of débridement, revascularization, local or free flap or skin equivalent, or graft reconstruction along with negative-pressure wound therapy between May 2011 and June 2013; there was a 1-year period during which both treatments were in use, and we did not include patients whose procedures were performed during this time in either group. Patients in both groups received standard off-loading and wound care. The patients lost to follow-up by 2 years (0.7% of the treatment group [one of 137] and 1.4% of the control group [two of 139]; p = 0.57) were excluded. The patients in the treatment and control groups had a mean age of 61 years and 60 years, respectively, and they were predominantly men in both groups (70% [95 of 136] versus 64% [88 of 137]; p = 0.32). There were no differences with respect to parameters associated with the likelihood of ulcer healing, such as diabetes and ulcer duration, ulcer grades and area, smoking, and arterial status. We compared the groups with respect to ulcer healing (complete epithelialization without discharge, maintained for at least 2 weeks, which was determined by an assessor not involved with clinical care) in a 2-year follow-up, the proportion of ulcers that healed by 6 months, major amputation, recurrence, and complications in the 2-yea
{"title":"Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers.","authors":"Yan Chen, Xiaocong Kuang, Jia Zhou, Puxiang Zhen, Zi-san Zeng, Zhenxun Lin, Wei Gao, Lihuan He, Yi Ding, Guangwei Liu, Shaohua Qiu, Annie Qin, W. Lu, Shan Lao, Jinmin Zhao, Qikai Hua","doi":"10.1097/CORR.0000000000001075","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001075","url":null,"abstract":"BACKGROUND\u0000The management of severe and recalcitrant diabetic foot ulcers is challenging. Distraction osteogenesis is accompanied by vascularization and regeneration of the surrounding tissues. Longitudinal distraction of the proximal tibia stimulates increased and prolonged blood flow to the distal tibia. However, the effects of transverse distraction of the proximal tibia cortex on severe and recalcitrant diabetic foot ulcers are largely unknown.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Does tibial cortex transverse distraction increase healing and decrease major amputation and recurrence of severe and recalcitrant diabetic foot ulcers compared with routine management (which generally included débridement, revascularization, negative pressure wound therapy, local or free flaps, or skin grafts as indicated)? (2) Does neovascularization and perfusion increase at the foot after the procedure? (3) What are the complications of tibial cortex transverse distraction in patients with severe and recalcitrant diabetic foot ulcers?\u0000\u0000\u0000METHODS\u0000Between July 2014 and March 2017, we treated 136 patients with diabetes mellitus and University of Texas Grade 2B to 3D ulcers (wound penetrating to the tendon, capsule, bone, or joint with infection and/or ischemia). The patients had failed to respond to treatment for at least 6 months, and their ulcers had a mean ± SD area of 44 cm ± 10 cm. All 136 patients underwent tibial cortex transverse distraction (partial corticotomy of the upper tibia, which was in normal condition, followed by 4 weeks of transverse distraction medially then laterally). We compared these patients with the last 137 consecutive patients we treated with standard surgical treatment, consisting of débridement, revascularization, local or free flap or skin equivalent, or graft reconstruction along with negative-pressure wound therapy between May 2011 and June 2013; there was a 1-year period during which both treatments were in use, and we did not include patients whose procedures were performed during this time in either group. Patients in both groups received standard off-loading and wound care. The patients lost to follow-up by 2 years (0.7% of the treatment group [one of 137] and 1.4% of the control group [two of 139]; p = 0.57) were excluded. The patients in the treatment and control groups had a mean age of 61 years and 60 years, respectively, and they were predominantly men in both groups (70% [95 of 136] versus 64% [88 of 137]; p = 0.32). There were no differences with respect to parameters associated with the likelihood of ulcer healing, such as diabetes and ulcer duration, ulcer grades and area, smoking, and arterial status. We compared the groups with respect to ulcer healing (complete epithelialization without discharge, maintained for at least 2 weeks, which was determined by an assessor not involved with clinical care) in a 2-year follow-up, the proportion of ulcers that healed by 6 months, major amputation, recurrence, and complications in the 2-yea","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"95 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85260342","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-26DOI: 10.1097/CORR.0000000000001061
D. D’Lima
Despite the extensive analysis of knee kinematics before and after TKA, the links to postoperative patient-reported outcomes have been less-than compelling. Some reasons for this include the differences in the biomechanics of the post-TKA knee relative to normal knees, the high patient-to-patient variation in kinematics, patient selection bias, and the activities studied being limited by the fluoroscopic field of view. Previous studies have shown that certain kinematic features, such as paradoxical or reverse roll-back and condylar lift-off, have negative biomechanical consequences but they have yet to be conclusively linked to clinical patientreported outcomes [3, 6, 7]. The kinematics of open-kinetic-chain knee extension are driven largely by the extensormechanism and by tibiofemoral articular geometry. Closed-kinetic-chain knee extension, with the foot planted on the ground, generates higher knee forces, is subject to greater anteroposterior motion, condylar lift-off, and axial rotation, and therefore has potential for unmasking instability [3, 6, 7]. The prospective study by Van Onsem and colleagues [14] comes closest of all the studies I have read thus far to linking specific patterns of post-operative kinematics to patient-reported outcomes. The authors found differences in closed-chain kinematics between clusters of patients with disparate patient-reported outcome measures (PROMs), but theywere careful not to speculate on the biomechanical reasons for the differences in knee kinematics. They appropriately qualified the title of their study as “A Preliminary Analysis” because their study raises more questions than it answers.
{"title":"CORR Insights®: Are TKA Kinematics During Closed Kinetic Chain Exercises Associated with Patient-reported Outcomes? A Preliminary Analysis.","authors":"D. D’Lima","doi":"10.1097/CORR.0000000000001061","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001061","url":null,"abstract":"Despite the extensive analysis of knee kinematics before and after TKA, the links to postoperative patient-reported outcomes have been less-than compelling. Some reasons for this include the differences in the biomechanics of the post-TKA knee relative to normal knees, the high patient-to-patient variation in kinematics, patient selection bias, and the activities studied being limited by the fluoroscopic field of view. Previous studies have shown that certain kinematic features, such as paradoxical or reverse roll-back and condylar lift-off, have negative biomechanical consequences but they have yet to be conclusively linked to clinical patientreported outcomes [3, 6, 7]. The kinematics of open-kinetic-chain knee extension are driven largely by the extensormechanism and by tibiofemoral articular geometry. Closed-kinetic-chain knee extension, with the foot planted on the ground, generates higher knee forces, is subject to greater anteroposterior motion, condylar lift-off, and axial rotation, and therefore has potential for unmasking instability [3, 6, 7]. The prospective study by Van Onsem and colleagues [14] comes closest of all the studies I have read thus far to linking specific patterns of post-operative kinematics to patient-reported outcomes. The authors found differences in closed-chain kinematics between clusters of patients with disparate patient-reported outcome measures (PROMs), but theywere careful not to speculate on the biomechanical reasons for the differences in knee kinematics. They appropriately qualified the title of their study as “A Preliminary Analysis” because their study raises more questions than it answers.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"93 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74104521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-26DOI: 10.1097/CORR.0000000000001074
S. Tsukamoto, Yuu Tanaka, A. Mavrogenis, A. Kido, M. Kawaguchi, C. Errani
BACKGROUND Denosumab, a monoclonal antibody that binds to receptor activation of nuclear factor-kappa ß ligand (RANKL), has been used as a drug to treat aggressive giant cell tumors of bone. It is unclear whether preoperative denosumab therapy is associated with the local recurrence risk in patients with giant cell tumors of bone treated with curettage. Early evidence suggests that denosumab treatment is associated with a reduction in local recurrence, but other studies have questioned that premise. Curettage after a short course of denosumab (3 to 4 months) has been recommended, especially for large, aggressive giant cell tumors in which complete curettage is difficult to achieve. No randomized studies have documented the benefit of this approach, and some investigators have reported higher local recurrence after denosumab treatment. Due to this confusion, we performed a systematic analysis of existing reports to attempt to answer this question and determine whether the appropriate preoperative denosumab therapy duration could be established. QUESTIONS/PURPOSES (1) Is the use of preoperative denosumab associated with local recurrence risk in patients with giant cell tumors of bone treated with curettage compared with those treated with curettage alone? (2) Is the preoperative denosumab therapy duration associated with local recurrence after curettage? METHODS We searched the PubMed, EMBASE, and CENTRAL databases on April 26, 2019 and included both randomized and non-randomized studies that compared local recurrence between patients who had giant cell tumors of bone and were treated with curettage after preoperative denosumab and patients treated with curettage alone. Two authors independently screened the studies. There were no randomized studies dealing with denosumab in giant cell tumors of bone, and generally, denosumab was used for more aggressive tumors. We assessed the quality of the included studies using the Risk of Bias Assessment tool for Non-randomized Studies, with a moderate overall risk of bias. We registered our protocol in PROSPERO (registration number CRD42019133288). We selected seven eligible studies involving 619 patients for the final analysis. RESULTS The proportion of patients with local recurrence ranged from 20% to 100% in the curettage with preoperative denosumab group and ranged from 0% to 50% in the curettage-alone group. The odds ratio of local recurrence ranged from 1.07 to 37.80 in no more than 6 months of preoperative denosumab duration group and ranged from 0.60 to 28.33 in more than 6 months of preoperative denosumab duration group. CONCLUSIONS The available evidence for the benefit of denosumab in more aggressive giant cell tumors is inconclusive, and denosumab treatment may even be associated with an increase in the proportion of patients experiencing local recurrence. Because there are no randomized studies and the existing studies are of poor quality due to indication bias (the most aggressive Campan
{"title":"Is Treatment with Denosumab Associated with Local Recurrence in Patients with Giant Cell Tumor of Bone Treated with Curettage? A Systematic Review.","authors":"S. Tsukamoto, Yuu Tanaka, A. Mavrogenis, A. Kido, M. Kawaguchi, C. Errani","doi":"10.1097/CORR.0000000000001074","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001074","url":null,"abstract":"BACKGROUND\u0000Denosumab, a monoclonal antibody that binds to receptor activation of nuclear factor-kappa ß ligand (RANKL), has been used as a drug to treat aggressive giant cell tumors of bone. It is unclear whether preoperative denosumab therapy is associated with the local recurrence risk in patients with giant cell tumors of bone treated with curettage. Early evidence suggests that denosumab treatment is associated with a reduction in local recurrence, but other studies have questioned that premise. Curettage after a short course of denosumab (3 to 4 months) has been recommended, especially for large, aggressive giant cell tumors in which complete curettage is difficult to achieve. No randomized studies have documented the benefit of this approach, and some investigators have reported higher local recurrence after denosumab treatment. Due to this confusion, we performed a systematic analysis of existing reports to attempt to answer this question and determine whether the appropriate preoperative denosumab therapy duration could be established.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) Is the use of preoperative denosumab associated with local recurrence risk in patients with giant cell tumors of bone treated with curettage compared with those treated with curettage alone? (2) Is the preoperative denosumab therapy duration associated with local recurrence after curettage?\u0000\u0000\u0000METHODS\u0000We searched the PubMed, EMBASE, and CENTRAL databases on April 26, 2019 and included both randomized and non-randomized studies that compared local recurrence between patients who had giant cell tumors of bone and were treated with curettage after preoperative denosumab and patients treated with curettage alone. Two authors independently screened the studies. There were no randomized studies dealing with denosumab in giant cell tumors of bone, and generally, denosumab was used for more aggressive tumors. We assessed the quality of the included studies using the Risk of Bias Assessment tool for Non-randomized Studies, with a moderate overall risk of bias. We registered our protocol in PROSPERO (registration number CRD42019133288). We selected seven eligible studies involving 619 patients for the final analysis.\u0000\u0000\u0000RESULTS\u0000The proportion of patients with local recurrence ranged from 20% to 100% in the curettage with preoperative denosumab group and ranged from 0% to 50% in the curettage-alone group. The odds ratio of local recurrence ranged from 1.07 to 37.80 in no more than 6 months of preoperative denosumab duration group and ranged from 0.60 to 28.33 in more than 6 months of preoperative denosumab duration group.\u0000\u0000\u0000CONCLUSIONS\u0000The available evidence for the benefit of denosumab in more aggressive giant cell tumors is inconclusive, and denosumab treatment may even be associated with an increase in the proportion of patients experiencing local recurrence. Because there are no randomized studies and the existing studies are of poor quality due to indication bias (the most aggressive Campan","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"102 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77997213","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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