OT

Platelet-rich plasma discussion was most accessed Orthopedics Today article in 2009

Top-read articles of last year show the varied interests and concerns of our readers.

A clinical Round Table discussion on the role of platelet-rich plasma in connective tissue repair was the most read article appearing in Orthopedics Today and on the ORTHOSuperSite.com in 2009.

The Top-10 article list was generated by an analysis of the number of times an article was opened on the ORTHOSuperSite.com Web site. The Web site contains articles from Orthopedics Today, Orthopaedics Today Europe and the peer-reviewed journal Orthopedics.

The list includes a mix of articles on clinical treatments, health care reform, and ongoing or dismissed litigation. This is the second consecutive year that a Round Table discussion was the most-read article.

“This list of Top 10 read articles represents the broad interest of our readers in keeping up with our profession and the changes that are affecting it,” Orthopedics Today Chief Medical Editor Douglas W. Jackson, MD, said. “It represents the strength of Orthopedics Today and its broad coverage of the field of orthopedics.”

In terms of the most-accessed article on platelet-rich plasma, Jackson said, “Our readers have a great interest in treatments for degenerative articular problems that can be applied directly, via arthroscopy or injected locally, and have minimal side effects.”

As we look to the future there will be an increased interest in the issues that affect the business-side of orthopedics.

“I think changing health policy and issues regarding patient care will be of increasing interest in 2010,” Jackson said.

The following is a list and summaries of the Top 10 articles of 2009 that were compiled by the Orthopedics Today staff.

Top 10

Surgeons discuss PRP for tissue repair

In a Round Table discussion, orthopedists shared their experiences using platelet-rich plasma for connective tissue repair.

“There has been a growing interest in the use of ‘biologics’ in orthopedics, and platelet-rich plasma represents an autologous source of potent bioactive [growth] factors,” Steven P. Arnoczky, DVM, the moderator of the discussion, told Orthopedics Today. “While the benefits of growth factors in enhancing cell proliferation and matrix synthesis have been well documented in numerous in vitro and in vivo pre-clinical studies, the potential efficacy of platelet-rich plasma in various clinical applications has yet to be conclusively demonstrated. I believe the Round Table was able to provide valuable insight into how several orthopedic thought-leaders currently view this technology and are applying it in their practices.”

The Round Table participants noted a wide range of indications for using platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM), such as rotator cuff repair, knee ligament reconstruction, treating isolated meniscus tears that are not associated with ACL tears or reconstructions, and chronic tendinopathy. Compared with control groups, the participants reported decreased narcotic use, lower rates of tunnel expansion and osteolysis, and improved pain scores in patients treated with PRP or PRFM.

Device maker executives plead guilty to conducting unauthorized trials

Of all the articles published at OrthoSupersite.com last year, the second most accessed concerned the June indictment against Norian Corp, its parent company Synthes, and four Synthes executives for charges related to allegedly conducting unauthorized clinical trials.

In July, two of the executives, Michael D. Huggins and John J. Walsh, entered guilty pleas to the charges against them, according to a media report.

Charges in the case mostly concerned use of Norian XR and Norian SRS bone cement during testing and surgeries completed from May 2002 until fall 2004.

Several felony counts were lodged against Norian, while Synthes was charged with 44 misdemeanor counts.

In addition to Huggins and Walsh, the two Synthes executives also each charged with one misdemeanor count of shipping adulterated and misbranded Norian XR in interstate commerce were Thomas B. Higgins and Richard E. Bohner, according to a press release from the office of the United States Attorney for the Eastern District of Pennsylvania.

Apophyseal avulsion fractures of the hip and pelvis

In the March issue of Orthopedics, Bart I. McKinney, MD, and colleagues outlined the importance of understanding and properly treating apophyseal avulsion fractures of the hip and pelvis — injuries that can be dangerous for an adolescent athlete.

McKinney’s group reported that proper diagnosis and treatment will usually result in a successful nonsurgical treatment, though they stressed that these fractures can be easily missed. The key to success with nonoperative treatment was, according to the study, a five-stage rehabilitation protocol.

Regarding surgical treatment, researchers recommended it be reserved for painful nonunions and symptomatic exostosis.

The team also covered common complications of the fractures, making note of painful nonunion and exostosis. Further, they warned, osteonecrosis could develop in patients with apophyseal fractures of the greater trochanter regardless of the treatment method used.

Commentary notes rapid health care reform

In his March commentary, Orthopedics Today Chief Medical Editor Douglas W. Jackson, MD, expressed his surprise at recent expansions to health care entitlement programs before the unveiling of the president’s plans for health care reform in his commentary “Health care reform: It is happening faster than most of us are aware.”

“I am amazed at how quickly these new entitlement programs have advanced,” he wrote. “This has occurred without many debates on the long-term consequences of the undetermined financial costs or on the timing of the programs during a yet-to-be-defined form of national health insurance.”

Jackson concluded, “This year we will face imposing challenges as proposed and enacted economic stimulus and health care reform bills alter the financing and practice of medicine and, concomitantly, the care of our patients.”

Stryker division, employees face indictments

The fifth most popular article at ORTHOSupersite.com in 2009 was a 1st on the Web from March about a federal grand jury probe of Stryker’s biotech division.

In a follow-up piece in October, we covered news that the federal grand jury of the U.S. Attorney’s Office of the District of Massachusetts charged Stryker Biotech LLC, its former president and some current sales managers with fraudulently promoting the improper use of medical devices in spine and long bone surgeries.

A Dec. 22, 2009 hearing was scheduled.

If convicted on all charges, the division faces fines of more than $500,000 on each count. The executives face various combinations of imprisonment and fines if convicted of the charges against them.

The U.S. attorney investigated the Stryker Biotech for submitting false reports to the FDA, illegally promoting some of its products, and selling misbranded medical devices, the ORTHOSupersite.com article stated.

Stryker said in a regulatory filing that the investigations are related to its OP-1 product and Calstrux bone filler.

Arthroscopic management may be useful for treating hip impingement

Arthroscopic hip impingement surgery may lead to pain relief and restored activity in patients with femoroacetabular impingement.

Dean K. Matsuda, MD, discussed the indications and surgical considerations for arthroscopic management of femoroacetabular impingement (FAI) at Orthopedics Today Hawaii 2009.

“I think that FAI is here to stay,” Matsuda said. “If you are thinking labral tear, think FAI. Isolated labral tears are relatively uncommon. Both open and arthroscopic procedures [in] short-term studies appear to be effective at pain relief and activity restoration. [There are] better outcomes in patients with less cartilage damage, suggesting earlier surgical intervention may be appropriate.”

While an extensive literature review of studies regarding open and arthroscopic treatment for hip impingement revealed insufficient evidence to determine definitive treatment guidelines for FAI, Matsuda and colleagues found that outcome instruments in these studies showed improved pain relief and activity levels.

Matsuda noted that arthroscopic treatment may be beneficial for young athletic patients with symptomatic FAI and may have a role for patients with mild arthrosis. However, he stated that the procedure does not have a place for the treatment of patients with advanced arthrosis and noted that it is still unclear whether the procedure can prevent arthritis.

Judge dismisses whistleblower lawsuit against Medtronic surgeons

Dismissal of a highly publicized whistleblower lawsuit against Medtronic spine surgeons was the seventh most read article published in 2009 at OrthoSupersite.com.

In March, a federal judge dismissed the lawsuit, filed in 2008 by two ex-Medtronic employees. It accused spine surgeons, spinal device distributors and others of accepting kickbacks from Medtronic.

Medtronic was not directly named in the lawsuit, which was dismissed because it had already been sufficiently aired in the court and media.

The judge blocked the plaintiffs’ motion to file an amended version of their complaint.

THA revisions in the United States

In our 4 Questions interview in October, Douglas W. Jackson, MD, interviewed Kevin J. Bozic, MD, about revision hip arthroplasty rates in the United States.

Bozic talked about the increase that has been seen, attributing it primarily to increased incidences in primary THA procedures, an expansion of the indications for THA to include younger, more active patients, and finally limitations in implant longevity.

In 2005, Bozic said, researchers with the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) made a proposal to the Center for Medicare & Medicaid Services and the National Center for Health Statistics to create a series of more specific, clinically relevant ICD-9 diagnosis and procedure codes.

These codes were adopted and introduced in October 2005, although Bozic it is unclear how commonly and appropriately they are being used by surgeons and administrators. Still, their use could be invaluable.

“Due to changes to THA-related administrative codes that were introduced in 2005, we now have the ability to use administrative claims data to evaluate the cause of THA failure and the types of revision THA procedures that are performed across the entire United States,” Bozic said. “This information will be valuable in guiding future research, implant design, and clinical decision making in THA.”

Intramedullary hip screw vs. standard compression hip screws

In Orthopedics, a study by Bruce H. Ziran, MD, and colleagues revealed that differences in the acute rehabilitation characteristics in patients between the intramedullary hip screw and the compression hip screw could be noted through the Functional Independence Measure (FIM).

Ninety-four patients were treated with either intramedullary or compression hip screws. Bed mobility, bed transfer, gait independence and distance ambulated were all evaluated.

The intramedullary group performed better with bed transfers, ambulatory ability at discharge and overall gait distance at discharge. In addition, skin-to-skin operative time and estimated blood loss were significantly less for the intramedullary group.

“Hip fractures remain one of the most prevalent fractures in the elderly population,” Ziran told Orthopedics Today. “Past debates focused on perioperative issues such as healing, blood loss and complications. The outcome of such debates found little difference between existing techniques, so the emerging variables to address include optimization of recovery and cost efficacy of treatment. This study examined differences in the rate of recovery using different techniques of fixation and found subtle differences between intramedullary and extramedullary techniques.”

Surgical treatment of distal tibia fractures: A comparison of medial and lateral plating

In the March issue of Orthopedics, Taiwanese researchers wrote that both medial and lateral plating were functionally successful — although lateral plating was found to have more advantages and fewer complications than medial plating.

Yih-Shiunn Lee, MD, and a team of researchers expanded upon the relatively little existing literature for the use of the lateral approach in the treatment of distal tibial and fibular fractures while forming the first reports to compare medial and lateral plating for the treatment of distal tibial fractures.

“Both medial and lateral plating for treating distal tibial fractures achieved good functional outcomes with a low malunion rate; however, the lateral plating group had a lower complication rate and fewer hardware problems,” the researchers wrote.

According to the authors, union rate, malunion rate, operative time, functional score and range of ankle motion were all determined to be similar between the medial and lateral plating groups.

A clinical Round Table discussion on the role of platelet-rich plasma in connective tissue repair was the most read article appearing in Orthopedics Today and on the ORTHOSuperSite.com in 2009.

The Top-10 article list was generated by an analysis of the number of times an article was opened on the ORTHOSuperSite.com Web site. The Web site contains articles from Orthopedics Today, Orthopaedics Today Europe and the peer-reviewed journal Orthopedics.

The list includes a mix of articles on clinical treatments, health care reform, and ongoing or dismissed litigation. This is the second consecutive year that a Round Table discussion was the most-read article.

“This list of Top 10 read articles represents the broad interest of our readers in keeping up with our profession and the changes that are affecting it,” Orthopedics Today Chief Medical Editor Douglas W. Jackson, MD, said. “It represents the strength of Orthopedics Today and its broad coverage of the field of orthopedics.”

In terms of the most-accessed article on platelet-rich plasma, Jackson said, “Our readers have a great interest in treatments for degenerative articular problems that can be applied directly, via arthroscopy or injected locally, and have minimal side effects.”

As we look to the future there will be an increased interest in the issues that affect the business-side of orthopedics.

“I think changing health policy and issues regarding patient care will be of increasing interest in 2010,” Jackson said.

The following is a list and summaries of the Top 10 articles of 2009 that were compiled by the Orthopedics Today staff.

Top 10

Surgeons discuss PRP for tissue repair

In a Round Table discussion, orthopedists shared their experiences using platelet-rich plasma for connective tissue repair.

“There has been a growing interest in the use of ‘biologics’ in orthopedics, and platelet-rich plasma represents an autologous source of potent bioactive [growth] factors,” Steven P. Arnoczky, DVM, the moderator of the discussion, told Orthopedics Today. “While the benefits of growth factors in enhancing cell proliferation and matrix synthesis have been well documented in numerous in vitro and in vivo pre-clinical studies, the potential efficacy of platelet-rich plasma in various clinical applications has yet to be conclusively demonstrated. I believe the Round Table was able to provide valuable insight into how several orthopedic thought-leaders currently view this technology and are applying it in their practices.”

The Round Table participants noted a wide range of indications for using platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM), such as rotator cuff repair, knee ligament reconstruction, treating isolated meniscus tears that are not associated with ACL tears or reconstructions, and chronic tendinopathy. Compared with control groups, the participants reported decreased narcotic use, lower rates of tunnel expansion and osteolysis, and improved pain scores in patients treated with PRP or PRFM.

Device maker executives plead guilty to conducting unauthorized trials

Of all the articles published at OrthoSupersite.com last year, the second most accessed concerned the June indictment against Norian Corp, its parent company Synthes, and four Synthes executives for charges related to allegedly conducting unauthorized clinical trials.

In July, two of the executives, Michael D. Huggins and John J. Walsh, entered guilty pleas to the charges against them, according to a media report.

Charges in the case mostly concerned use of Norian XR and Norian SRS bone cement during testing and surgeries completed from May 2002 until fall 2004.

Several felony counts were lodged against Norian, while Synthes was charged with 44 misdemeanor counts.

In addition to Huggins and Walsh, the two Synthes executives also each charged with one misdemeanor count of shipping adulterated and misbranded Norian XR in interstate commerce were Thomas B. Higgins and Richard E. Bohner, according to a press release from the office of the United States Attorney for the Eastern District of Pennsylvania.

Apophyseal avulsion fractures of the hip and pelvis

In the March issue of Orthopedics, Bart I. McKinney, MD, and colleagues outlined the importance of understanding and properly treating apophyseal avulsion fractures of the hip and pelvis — injuries that can be dangerous for an adolescent athlete.

McKinney’s group reported that proper diagnosis and treatment will usually result in a successful nonsurgical treatment, though they stressed that these fractures can be easily missed. The key to success with nonoperative treatment was, according to the study, a five-stage rehabilitation protocol.

Regarding surgical treatment, researchers recommended it be reserved for painful nonunions and symptomatic exostosis.

The team also covered common complications of the fractures, making note of painful nonunion and exostosis. Further, they warned, osteonecrosis could develop in patients with apophyseal fractures of the greater trochanter regardless of the treatment method used.

Commentary notes rapid health care reform

In his March commentary, Orthopedics Today Chief Medical Editor Douglas W. Jackson, MD, expressed his surprise at recent expansions to health care entitlement programs before the unveiling of the president’s plans for health care reform in his commentary “Health care reform: It is happening faster than most of us are aware.”

“I am amazed at how quickly these new entitlement programs have advanced,” he wrote. “This has occurred without many debates on the long-term consequences of the undetermined financial costs or on the timing of the programs during a yet-to-be-defined form of national health insurance.”

Jackson concluded, “This year we will face imposing challenges as proposed and enacted economic stimulus and health care reform bills alter the financing and practice of medicine and, concomitantly, the care of our patients.”

Stryker division, employees face indictments

The fifth most popular article at ORTHOSupersite.com in 2009 was a 1st on the Web from March about a federal grand jury probe of Stryker’s biotech division.

In a follow-up piece in October, we covered news that the federal grand jury of the U.S. Attorney’s Office of the District of Massachusetts charged Stryker Biotech LLC, its former president and some current sales managers with fraudulently promoting the improper use of medical devices in spine and long bone surgeries.

A Dec. 22, 2009 hearing was scheduled.

If convicted on all charges, the division faces fines of more than $500,000 on each count. The executives face various combinations of imprisonment and fines if convicted of the charges against them.

The U.S. attorney investigated the Stryker Biotech for submitting false reports to the FDA, illegally promoting some of its products, and selling misbranded medical devices, the ORTHOSupersite.com article stated.

Stryker said in a regulatory filing that the investigations are related to its OP-1 product and Calstrux bone filler.

Arthroscopic management may be useful for treating hip impingement

Arthroscopic hip impingement surgery may lead to pain relief and restored activity in patients with femoroacetabular impingement.

Dean K. Matsuda, MD, discussed the indications and surgical considerations for arthroscopic management of femoroacetabular impingement (FAI) at Orthopedics Today Hawaii 2009.

“I think that FAI is here to stay,” Matsuda said. “If you are thinking labral tear, think FAI. Isolated labral tears are relatively uncommon. Both open and arthroscopic procedures [in] short-term studies appear to be effective at pain relief and activity restoration. [There are] better outcomes in patients with less cartilage damage, suggesting earlier surgical intervention may be appropriate.”

While an extensive literature review of studies regarding open and arthroscopic treatment for hip impingement revealed insufficient evidence to determine definitive treatment guidelines for FAI, Matsuda and colleagues found that outcome instruments in these studies showed improved pain relief and activity levels.

Matsuda noted that arthroscopic treatment may be beneficial for young athletic patients with symptomatic FAI and may have a role for patients with mild arthrosis. However, he stated that the procedure does not have a place for the treatment of patients with advanced arthrosis and noted that it is still unclear whether the procedure can prevent arthritis.

Judge dismisses whistleblower lawsuit against Medtronic surgeons

Dismissal of a highly publicized whistleblower lawsuit against Medtronic spine surgeons was the seventh most read article published in 2009 at OrthoSupersite.com.

In March, a federal judge dismissed the lawsuit, filed in 2008 by two ex-Medtronic employees. It accused spine surgeons, spinal device distributors and others of accepting kickbacks from Medtronic.

Medtronic was not directly named in the lawsuit, which was dismissed because it had already been sufficiently aired in the court and media.

The judge blocked the plaintiffs’ motion to file an amended version of their complaint.

THA revisions in the United States

In our 4 Questions interview in October, Douglas W. Jackson, MD, interviewed Kevin J. Bozic, MD, about revision hip arthroplasty rates in the United States.

Bozic talked about the increase that has been seen, attributing it primarily to increased incidences in primary THA procedures, an expansion of the indications for THA to include younger, more active patients, and finally limitations in implant longevity.

In 2005, Bozic said, researchers with the American Academy of Orthopaedic Surgeons (AAOS) and the American Association of Hip and Knee Surgeons (AAHKS) made a proposal to the Center for Medicare & Medicaid Services and the National Center for Health Statistics to create a series of more specific, clinically relevant ICD-9 diagnosis and procedure codes.

These codes were adopted and introduced in October 2005, although Bozic it is unclear how commonly and appropriately they are being used by surgeons and administrators. Still, their use could be invaluable.

“Due to changes to THA-related administrative codes that were introduced in 2005, we now have the ability to use administrative claims data to evaluate the cause of THA failure and the types of revision THA procedures that are performed across the entire United States,” Bozic said. “This information will be valuable in guiding future research, implant design, and clinical decision making in THA.”

Intramedullary hip screw vs. standard compression hip screws

In Orthopedics, a study by Bruce H. Ziran, MD, and colleagues revealed that differences in the acute rehabilitation characteristics in patients between the intramedullary hip screw and the compression hip screw could be noted through the Functional Independence Measure (FIM).

Ninety-four patients were treated with either intramedullary or compression hip screws. Bed mobility, bed transfer, gait independence and distance ambulated were all evaluated.

The intramedullary group performed better with bed transfers, ambulatory ability at discharge and overall gait distance at discharge. In addition, skin-to-skin operative time and estimated blood loss were significantly less for the intramedullary group.

“Hip fractures remain one of the most prevalent fractures in the elderly population,” Ziran told Orthopedics Today. “Past debates focused on perioperative issues such as healing, blood loss and complications. The outcome of such debates found little difference between existing techniques, so the emerging variables to address include optimization of recovery and cost efficacy of treatment. This study examined differences in the rate of recovery using different techniques of fixation and found subtle differences between intramedullary and extramedullary techniques.”

Surgical treatment of distal tibia fractures: A comparison of medial and lateral plating

In the March issue of Orthopedics, Taiwanese researchers wrote that both medial and lateral plating were functionally successful — although lateral plating was found to have more advantages and fewer complications than medial plating.

Yih-Shiunn Lee, MD, and a team of researchers expanded upon the relatively little existing literature for the use of the lateral approach in the treatment of distal tibial and fibular fractures while forming the first reports to compare medial and lateral plating for the treatment of distal tibial fractures.

“Both medial and lateral plating for treating distal tibial fractures achieved good functional outcomes with a low malunion rate; however, the lateral plating group had a lower complication rate and fewer hardware problems,” the researchers wrote.

According to the authors, union rate, malunion rate, operative time, functional score and range of ankle motion were all determined to be similar between the medial and lateral plating groups.