Presented by OrthoEvidence

Did You Know? The process of becoming an orthopaedic surgeon can be very different, depending on where you practice. This study found that ‘competency-based’ training programs are not always the norm, and the number of cases required to become licensed as an orthopaedic surgeon range from 340 to over 1200. 

In today's edition:

🏥 Total hip arthroplasty vs. hemiarthroplasty for displaced femoral neck fracture

🍲 Peri-operative nutrition: the next big focus?

💊 Minimizing opioid use with cryoneurolysis before TKA

Costing individuals, healthcare systems, and society billions of dollars, hip fractures are a major cause of disability, particularly in the elderly. For displaced femoral neck fractures, arthroplasty is preferred over fracture fixation. However, there is conflicting evidence on whether total hip arthroplasty (THA) or hemiarthroplasty (HA) provides the best outcomes. A systematic review of the latest evidence was of interest to compare the two options.

16 randomized trials, enrolling a total of 3,084 patients with displaced femoral neck fractures, were included in this systematic review and meta-analysis comparing THA and HA. 

• The odds of revision surgery were similar between THA and HA (p=0.44). This result was robust in the sub-group analysis by study quality (low risk of bias; high risk of bias).

• Functional outcomes were similar between the two groups (p=0.57).

• Pooled outcomes for health-related quality of life were significantly better in the THA group compared to the HA group (p=0.001).

• The odds of mortality, dislocation, and periprosthetic fracture were all not significantly different between THA and HA (p>0.05 for all).

• Pooled operative time was significantly shorter in the HA group (p=0.001), with a mean difference of 21.7 minutes (95% CI 8.7, 34.8).

Bottom line. This review found no significant difference between THA and HA in the odds of revision, functional outcomes, mortality, dislocation, or periprosthetic fracture. There may be a small benefit in quality of life in favour of THA, and a slightly shorter operative time in favour of HA.

Check out our full ACE Report on this paper.

Eat well, be well. While not quite this simple, nutrition is a powerful tool in the preventative medicine toolkit. But does perioperative nutrition really have the potential to improve surgical outcomes? There is a surprising amount of evidence to suggest that this is the case, especially for patients with pre-existing conditions that may affect their post-surgical recovery.

The potential to mitigate these surgical risks by modulating the body's stress response through appropriate nutrition is precisely what makes perioperative nutritional interventions so enthralling. Pre-operative carbohydrate loading, oral nutritional supplements, amino acid supplementation, and immunonutrition have all been shown to successfully regulate energy and protein metabolism during the surgical stress response.

In this OE Insight, we reflect on the future of patient care and what may be moving us towards a focus on nutrition. We also discuss the surgical stress response, the risks associated with it, and how nutrition can play a role in optimizing healing and recovery for orthopaedic patients.

You can read the full OE Original on peri-operative nutrition and orthopaedics here.

Surgeons are increasingly looking to non-opioid interventions to control pain. Cryoneurolysis, which involves the treatment of nerves using cold treatment, has been reported to effectively reduce pain for patients undergoing TKA, but high-quality randomized trials were lacking.

124 patients with osteoarthritis scheduled for a primary unilateral total knee arthroplasty were randomized to receive cryoneurolysis in the week prior to surgery (n=62) or standard pre-operative care (n=62). The primary outcome of interest was cumulative opioid consumption at 6 weeks. Secondary outcomes of interest included pain, function, and knee health.

• There were no significant differences in cumulative opioid consumption at 6 weeks between the two groups in the intent-to-treat analysis (p=0.084). However, in the per-protocol analysis, the cryoneurolysis group consumed significantly less opioids at 72 hours, 6 weeks, and 12 weeks post-operation.

• Improvements in knee health scores (KOOS JR) were significantly greater in the cryoneurolysis group at all time-points (p<0.0001 for all). 

• Range of motion and the improvement in timed up and go (TUG) test scores were similar between the two groups.

• The improvement in current pain scores was significantly better in the cryoneurolysis group in the first 72 hours and 2 weeks (p<0.01 for both).

Bottom line. Cryoneurolysis prior to TKA could help effectively manage post-operation. Despite not meeting its primary endpoint of opioid consumption at 6 weeks, the per-protocol analysis found reduced opioid consumption at several time-points, lower pain scores in the first 2 weeks post-operation, and greater improvement in knee health scores.

Check out our full ACE Report on this paper.

Stopped Early for Benefit – What do you do when there’s a clear benefit to one treatment over the other in an RCT? In this OE Original, we talk about stopping trials early for benefit, the benefits and drawbacks of doing so, and what you should consider when interpreting such studies in the literature! (Read)

10 Things You Didn't Know About This Surgeon – In today’s surgeon feature, we chatted with Dr. Michelle Ghert, professor of orthopedic surgery and principal investigator for the PARITY and SAFETY trials. You can check out our interview with her on the PARITY trial here. (Read)

Data Scan: Sports Medicine – Powered by our OE MIND database, we surveyed over 430 RCTs related to sports medicine, covering over 300 treatments. In this OE Original, we break down key players in the sports medicine field (#3: DePuy Synthes), the most frequently researched conditions, and where sports medicine research is being conducted! (Read)

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