Presented by OrthoEvidence

Good Morning. Are you one of the 30-50% of surgeons suffering from burnout? A recent paper has a couple tips for you:
1)    Take time for yourself, your family and friends.
2)    Manage your operating room time so you have time for the most difficult patients.
3)    And a key tip: rediscover your love for orthopaedics by distancing yourself from it.

In today's edition:

📱 The rise of digital rehabilitation

🕟 Watchful waiting vs. physical therapy for frozen shoulder

🔬 Minimally invasive medial femoral approach in TKA

Rehabilitation is essential to the field of orthopaedics, being an integral part of post-operative recovery and the management of musculoskeletal injuries. But its expensive - especially for in-person, physiotherapist-led interventions. That’s where digitally assisted rehabilitation comes in.

Digitally assisted rehabilitation took off during the pandemic as physicians and surgeons were forced to go remote. One of the advantages of digitally assisted rehabilitation is the ability to provide personalized, accessible, and low-cost rehab treatment. And some studies have found it to result in greater adherence. But what about effectiveness? 

 
In this OE Original, we break down the science on digitally assisted postoperative rehabilitation, including the major companies investing in rehabilitation technologies, future evidence coming down the pipeline, and most importantly, the evidence on the clinical effectiveness of digital interventions for postoperative rehabilitation.

Read the full OE Original here.

Driving down patient costs while improving patient outcomes – the fundamentals of value-based care. But finding the balance between these two important factors is not always easy. In this study, researchers aimed to do just that by comparing the clinical and cost effectiveness of watchful waiting, a more conservative approach involving patient monitoring, and physical therapy, for patients with adhesive capsulitis (aka, frozen shoulder).

61 patients with idiopathic frozen shoulder were randomized to receive either watchful waiting (WW; n=31) or physical therapy (PT; n=30). The primary outcome of interest was the American Shoulder and Elbow Surgeons score (ASES) questionnaire. Secondary outcomes of interest included pain scores on a Visual Analog Scale (VAS), the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, direct patient healthcare costs, and patient value (defined as the 12-month ASES score divided by healthcare costs). Outcomes were assessed up to 12 months.

• Both treatment cohorts (WW and PT) showed significant improvements at each time point and for all PROMs (p<0.05 for all). Specifically, 31 patients (51.8%) assigned to WW and 30 patients (49.2%) to PT saw improvement.

• There was no significant difference in PROMs between treatment modalities at any time point (p>0.05 for all).

• Patients randomized to PT incurred 10X higher costs. The normalized mean difference in patient costs was 1,635.67 (95% CI: 967.19, 2,304.15; p<0.001).

• Patients in the PT group only achieved 16.9% of the patient value (normalized mean difference: -146.97; 95% CI: -207.47, -86.47; p<0.001).

Bottom line. While both watchful waiting and physical therapy improved patient outcomes, watchful waiting appears to be the cost-effective approach for managing primary adhesive capsulitis.

Check out the comprehensive analysis of this AAOS abstract here.

Total knee arthroplasty is well-established as the definitive treatment for end-stage knee osteoarthritis. But the optimal approach is not. The most common approach is the standard medial parapatellar approach; the long incision in the standard approach provides good visualization, but comes with a risk of patellofemoral problems. The mini-midvastus approach has thus gained popularity, but its efficacy in relation to the standard medial parapatellar approach is still debated. To settle the debate, a systematic review of the available evidence was needed.

 
12 studies, including a total of 788 knees, were included in this systematic review and meta-analysis comparing the minimally invasive medial parapatellar approach via the vastus medialis obliquus muscle vs. the standard medial parapatellar approach. Meta-analyses were performed for a host of outcomes including knee joint scores, pain, function, mobility, and operative time. 

• Pooled knee joint scores (KSS) were significantly better in the minimally invasive group compared to the standard approach group at 3 and 12 months (p<0.05 for both).

• Knee function scores were not significantly different between the two groups up to 12 months post-operation. However, post-operative pain scores at 3 months were significantly in favour of the minimally invasive group (p=0.001).

• Knee joint mobility (flexural activity) was superior in the minimally invasive group at 3 months compared to the standard approach (p=0.04). The duration of straight leg raise was also significantly longer in the minimally invasive group (p=0.01).

• Operative time was longer with the minimally invasive approach (p<0.0001). No differences in the pooled length of hospitalization, complication rate, or peri-operative blood loss were observed (p>0.05 for all).

Bottom line. Despite a longer operative time, a minimally-invasive medial parapatellar approach via the vastus medialis resulted in significantly better clinical outcomes, particularly in the first 3 months post-operation compared to the standard medial parapatellar approach.

Check out our full ACE Report on this paper.

History of the AO – In this OrthoJoe podcast, Dr’s Marc Swiontkowski and Mohit Bhandari sit down with Hans Kreder, Joseph Schatzker, and Marvin Tile for a fascinating conversation on the history of the AO: the leading education provider to healthcare professionals working in trauma and musculoskeletal disorders! (Watch)

BMI: Is the Gold Standard Losing Its Shine? – In this OE Insight, we discuss everything BMI, including its inception, its progression to the becoming the standard measure of obesity, its limitations, and alternatives that could help surgeons and clinicians make better decisions for their patients. (Read)

Hyaluronic Acid, Corticosteroid, and Knee Pain – In this OrthoPod, we sat down with Dr. Eric Babins, family physician, sports medicine expert, and owner of the Southland Sport Medicine Clinic in Calgary, Alberta. We discussed the existing knee injectable options for patients, his clinical experience treating athletes of all levels, and the essential importance of a good patient history. (Watch)

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