Presented by OrthoEvidence

Good Morning. Turns out December is a busy time for everyone but trauma surgeons: a retrospective study from 2018 found that trauma case volume was significantly lower in the winter months vs. the summer months. So if you see the trauma surgeons in the surgeon’s lounge looking like they’ve got nothing better to do, they probably don’t.

In today's edition:

🦵 Everything ACL reconstruction

🧠 Cognitive functional therapy for back pain

🏥 Partial vs. total knee arthroplasty

Anterior cruciate ligament (ACL) tears have hit some of our most beloved athletes, from Tom Brady to Zlatan Ibrahimovic. And they disproportionally affect young, active women – their risk of ACL injury has been reported to be as much as 35x higher than men. It’s also a predictor of osteoarthritis. So treatment is kind of a big deal.

But just how big is the ACL treatment market, and is ACL reconstruction really the best option? Using our Surgical Analytics platform, which has 173 RCTs on ACL treatment including over 15,000 patients, we ran some analyses to find out!

Market Analysis. ACL injuries cost roughly $7 billion to treat in the USD alone. For reconstruction, there are a host of fixation devices available, from buttons to bone plugs, to screws and cross-pin systems. The company with the greatest academic market share is Smith & Nephew, maker of the EndoButton graft fixation device. In 2nd place is Arthrex, followed by DePuy Synthes, ConMed, and Ethicon.

Reconstruction or rehab? Using our OE Meta-Analyzer, we compared ACL reconstruction and rehabilitation to see whether it provides any advantages in clinical efficacy or safety. We found that ACL reconstruction led to significantly better functional outcomes and a lower risk of adverse events compared to rehabilitation. However, there were no significant differences in re-rupture, ACL-specific injury scores, or pain scores. 

 
In the pipeline. According to clinicalTrials.gov, there are over 250 studies on ACL injury currently underway. Reconstruction is the most widely studied intervention, confirming that researchers are device manufacturers are still investing time and money in ACL reconstruction. 

Bottom line: The ACL reconstruction market is large and will likely grow in the coming years. Particularly for younger, more active patients, ACL reconstruction could provide advantages over rehabilitation, improving clinical outcomes and reducing the risk of adverse events.

We’ve all been attacked by a bout of back pain before. But for some people, it just never goes away. Chronic low back pain is one of the greatest sources of disability globally, so finding ways to management can have major benefits in patient quality of life and societal productivity.

 
Treating chronic low back pain is difficult, as it’s often a multifactorial condition. That’s where cognitive functional therapy (CFT) comes in: it’s an individualized, self-management intervention targeting the “cognitions, emotions and behaviours” that contribute to pain. There’s been some evidence of its effectiveness, but no large trials supporting its use…until now.

Published in The Lancet, the RESTORE Trial randomized 492 patients from 20 physio clinics across Australia to receive either usual care (n=165), CFT only (n=164), or CFT plus biofeedback (n=165). The primary clinical outcome was activity limitation at 13 weeks. The researchers also assessed the economic impact of the treatment with quality-adjusted life-years (QALYs).

•  For the primary outcome, both CFT only and CFT plus biofeedback were significantly more effective than usual care (p<0.0001) at 13- and 52-weeks follow-up. But no differences were observed between the two CFT groups. 

•  All secondary outcomes, like pain, pain catastrophizing, and fear-avoidance beliefs, both CFT groups were better than usual care up to 52-weeks follow up (p<0.0001 for all).

• Both CFT interventions were more effective than usual care and had lower societal costs (direct & indirect costs, productivity losses)

Bottom line: Cognitive functional therapy could be a promising (and cost-effective) treatment for patients with chronic low back pain. You can find an in-depth appraisal of this study on our website.

For those with the misfortune of having end-stage knee osteoarthritis, arthroplasty is the definitive treatment. Yet, despite over a million knee arthroplasties being performed every year, there are few randomized trials comparing uni-compartmental and total knee arthroplasty.

 
Uni-compartmental arthroplasty is usually cheaper & requires shorter recovery time, but there concerns with survivorship. Given the limited high-quality evidence on the topic, a randomized trial comparing the two options was needed.

Published in the Journal of Arthroplasty, researchers from United States randomized 107 patients with medial compartment knee osteoarthritis were randomized to receive a uni-compartmental knee arthroplasty (n=57) or a total knee arthroplasty (n=50). Outcomes of interest included patient-reported outcomes, perioperative outcomes, and radiographic outcomes, up to 6 months post-operation. 

• Uni-compartmental knee arthroplasty is faster to perform (p<0.001) and resulted in a shorter hospital stay (p<0.010) compared to total knee arthroplasty.

• Range of motion 6 weeks post-operation were significantly better in the uni-compartmental knee arthroplasty group (p=0.017).

• Time to return to work (p=0.346) and duration of opioid consumption (p=0.290) were similar in both groups.

• At 6 months post-op, patient-reported outcomes were similar between the uni-compartmental and total knee arthroplasty.

Bottom line: Survivorship & clinical outcomes needs to be studied beyond 6 months. But in the short-term, patients could experience favourable short-term and peri-operative outcomes with uni-compartmental knee arthroplasty.

 
You can check out our deep dive on this study here.

Why Most Published Research Findings Are False – renowned Stanford professor and physician John Ioannidis explains why for most study designs and settings, its more likely for a research claim to be false than true. This wildly popular paper has been cited over 12,000 times. (Read More)

On the Antiseptic Principle in the Practice of Surgery – in surgery, we stand on the shoulders of giants. Inspired by the works of Louis Pasteur, Joseph Lister’s 1867 paper initiated the use of antiseptic surgical methods.

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The Injectables –PRP outperformed corticosteroid for the treatment of chronic plantar fasciitis, significantly improving pain, function, and plantar fascia thickness at 6 months follow-up. 

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