Orthopedic studies

ACRONYMS AND DEFINITIONS

AAOS - American Academy of Orthopaedic Surgeons

ACL - Anterior cruciate ligament

ACR - American College of Rheumatology

LBP - Low back pain

OA - Osteoarthritis

PFR - Patellofemoral replacement

PHR - Partial hip replacement (hemiarthroplasty)

PKR - Partial knee replacement

PRP - Platelet-rich plasma

PT - Physical therapy

RCT - Randomized controlled trial

THR - Total hip replacement

TKR - Total knee replacement

UKR - Unicompartmental knee replacement

KNEE | ACL tear

Anterior cruciate ligament (ACL)

The anterior cruciate ligament (ACL) is a ligament in the knee that connects the femur bone to the tibia bone (see ACL illustration)
ACL tears often lead to knee instability, particularly in active people. In the United States, ACL tears are typically treated with surgical repair in active individuals.
Two studies detailed below compared early ACL repair to a watch-and-wait approach with optional repair after PT. The first study only enrolled active young adults aged 18 - 35 years, and the second study enrolled adults aged 18 - 65 years.

Early ACL Reconstruction vs Delayed Optional Reconstruction in Acute ACL Tear, NEJM (2010) [PubMed abstract]

A study in the NEJM enrolled 121 young, active adults with an acute ACL tear

Main inclusion criteria

Active individuals
18 - 35 years of age
ACL tear not more than 4 weeks old to a previously uninjured knee

Main exclusion criteria

Professional athletes
Patients who were less than moderately active
Total collateral ligament rupture
Full thickness cartilage lesion

Baseline characteristics

Average age - 26 years
Meniscal injury - 55%
Average KOOS4 score - 37

Randomized treatment groups

Group 1 (62 patients): Rehabilitation plus ACL reconstruction within 10 weeks (ACL repair group)
Group 2 (59 patients): Rehabilitation plus optional delayed ACL reconstruction (PT group)
In both groups, meniscal tears were treated as indicated based on MRI findings and clinical signs. In Group 1, there were 40 meniscal surgeries over the course of the study. In Group 2, there were 50 meniscal surgeries.

Primary outcome: Change from baseline to 2 years in the average score on four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) — pain, symptoms, function in sports and recreation, and knee-related quality of life (KOOS4; range of scores, 0 [worst] to 100 [best])

Results

Outcome	ACL repair	PT	1 vs 2
Duration: 2 years
Primary outcome (average change in KOOS4 score)	39.2	39.4	p=0.96
Return to preinjury activity level or higher	44%	36%	p=0.37
Over the course of the study, one subject in the ACL repair group did not have surgery, and 23 subjects (39%) in the PT group underwent ACL repair As-treated analysis (average change in KOOS4 score): ACL repair (n=60) - 39, PT group with surgery (n=23) - 39.8, PT group without surgery (n=36) - 39.2 (p=0.98) As-treated analysis (return to previous activity): ACL repair (n=60) - 44%, PT group with surgery (n=23) - 30%, PT group without surgery (n=36) - 39% (p=0.56)

Findings: In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy substantially reduced the frequency of surgical reconstructions.

Early ACL Reconstruction vs Delayed Optional Reconstruction - 5 year follow-up results, BMJ (2013) [PubMed abstract]

In the trial above, 120 of the 121 original participants were followed for 5 years. Results at 5 years are presented below.

Outcome	ACL repair	PT	1 vs 2
Duration: After 5 years, the following was seen
Primary outcome (KOOS4 score at 5 years)	80	82	p=0.45
Return to preinjury activity level	23%	20%	p=0.73
In the PT group, seven additional subjects ended up having surgical ACL repair from years 2 - 5 bringing the total number of ACL repairs in the PT group to 30 patients (51%) As-treated analysis (KOOS4 score at 5 years): ACL repair (n=59) - 80, PT group with surgery (n=30) - 81, PT group without surgery (n=29) - 82 (p=0.80) There was no significant difference in radiographic osteoarthritis between the two groups

Findings: In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.

Early ACL Repair vs PT with Optional Repair After 3 Months, BMJ (2021) [PubMed abstract]

The study enrolled 167 patients with a complete ACL tear that occurred within the last 2 months

Main inclusion criteria

Age 18 - 65 years
Acute (within 2 months) ACL tear

Main exclusion criteria

History of injury to ACL of the contralateral knee
Dislocated bucket handle lesion of the meniscus with an extension deficit

Baseline characteristics

Average age 31 years
Female sex - 40%
Average BMI - 24.7
ACL injured during sport - 88%
Average IKDC score - 46
Other MRI findings: Meniscal tear - 45% | MCL injury - 36% | LCL injury - 11% | Cartilage defect - 24%

Randomized treatment groups

Group 1 (85 patients): Early ACL repair (within 6 weeks of randomization)
Group 2 (82 patients): Three months of PT followed by optional repair

Primary outcome: Patients’ perceptions of symptoms, knee function, and ability to participate in sports, measured by the International Knee Documentation Committee (IKDC) score, assessed over a period of 24 months. A higher IKDC score reflects a more favourable rating for symptoms, knee function, and ability to participate in sporting activities (optimum score 100).

Results

Outcome	Early repair	PT + Optional repair	Comparisons
Duration: 2 years
ACL repair performed	96.5%	50%	N/A
Primary outcome (IKDC at 2 years)	84.7	79.4	Diff 5.3, 95%CI [0.6 - 9.9], p=0.026
IKDC at 12 months	81.6	74.4	Diff 7.1, 95%CI [1.9 - 12.4]
Meniscal repair procedures	24	17	N/A

Findings: In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction.

AAOS recommendations for ACL tear treatment

The AAOS has published an online form that gives recommendations for ACL tear treatment based on 5 patient characteristics
The form is available at this link - AAOS ACL tear recommendations

Summary

The first study among young, active adults found that a physical therapy and watch approach for ACL tears is safe and does not lead to any worse subjective (pain and function) or objective (radiographic) outcomes than an immediate repair approach. In the second study, a similar comparison also did not find any meaningful difference in outcomes. Both studies were unblinded which means patient biases for or against surgery were not controlled. Many patients perceive active interventions such as surgery as being more meaningful, so it's likely that the studies were biased towards surgery.
In summary, a watch-and-wait approach appears to be safe for ACL tears in most patients, including those who are active. At least 50% of patients will have a satisfactory outcome without surgery.

KNEE | Meniscal tear

Knee meniscus

The meniscus is a cartilage pad in the knee that serves as a cushion between the femur and tibia bones. It may become torn through acute trauma or normal wear-and-tear (see meniscus tear illustration and types of meniscal tears). A torn meniscus can cause pain and mechanical symptoms described as popping, locking, and catching. To address these symptoms, orthopedic surgeons often perform arthroscopic surgery, where they attempt to suture or remove the torn meniscus. Because of blood supply and tear patterns, less than 10% of meniscal tears can be sewn back together (meniscal repair), and the remainder must be trimmed away (meniscectomy). Arthroscopic meniscectomy is one of the most common orthopedic procedures performed in the U.S.
A number of studies have now looked at the effects of this procedure on patient outcomes. The FIDELITY study was a groundbreaking trial that compared meniscectomy to a sham procedure so that patients were completely blind to the treatment they received. Two other studies compared surgery to physical therapy; one was in patients with OA, and the other was in young adults. All three studies are detailed below.

FIDELITY Study - Surgical Meniscectomy vs Sham Surgery for Medial Meniscal Tear, NEJM (2013) [PubMed abstract]

The FIDELITY study enrolled 146 patients with a symptomatic medial meniscal tear

Main inclusion criteria

Age 35 - 65 years
Knee pain > 3 months that was unresponsive to conservative treatment
Clinical findings consistent with a medial meniscal tear
MRI was performed on all patients to confirm the presence of a meniscal tear, but trial eligibility was only confirmed once the tear was observed on arthroscopy

Main exclusion criteria

Traumatic onset of symptoms
Osteoarthritis

Baseline characteristics

Average age 52 years
Average BMI 27
Median duration of pain - 10 months
Pain onset: Gradual 63 - 69% | After exercise or hard work 17% | Suddenly or after twisting 14 - 18%
Symptoms of catching or locking - 47%
Average Lysholm score - 60
Average WOMET score - 54
Average knee pain score after exercise - 6

Randomized treatment groups

Group 1 (70 patients): Medial meniscectomy
Group 2 (76 patients): Sham surgery (meniscectomy was faked, nothing was actually done to meniscus)
Postoperatively, all patients were given a graduated exercise program to follow

Primary outcome: Changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores (each ranging from 0 to 100, with lower scores indicating more severe symptoms) and in knee pain after exercise (rated on a scale from 0 to 10, with 0 denoting no pain) at 12 months after the procedure

Results

Outcome	Meniscectomy	Sham	Comparisons
Duration: 12 months
Average Lysholm score improvement	21.7	23.3	diff -1.6, 95%CI [-7.2 to 4.0]
Average WOMET score improvement	24.6	27.1	diff -2.5, 95%CI [-9.2 to 4.1]
Average knee pain score improvement	3.1	3.3	diff -0.1, 95%CI [-0.9 to 0.7]
A subgroup of patients (Meniscal repair - 14 patients, Sham - 18 patients) had acute onset of symptoms. When these patients were analyzed separately, there was no significant difference in their outcomes, although this analysis was underpowered. Two patients in the meniscal repair group required additional knee surgery, and five patients in the sham group eventually had knee surgery. This difference was nonsignificant.

Findings: In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.

FIDELITY Study - Meniscectomy vs Sham Surgery for Medial Meniscal Tear: Two-year Follow-up, BMJ (2018) [PubMed abstract]

In the FIDELITY study above, 144 of the original 146 participants were followed for 2 years. Results at 2 years are presented below

Outcome	Meniscectomy	Sham	Comparisons
Duration: 2 year follow-up
Average Lysholm score improvement	23.1	26.3	diff -3.2, 95%CI [-8.9 to 2.4]
Average WOMET score improvement	27.3	31.6	diff -4.3, 95%CI [-11.3 to 2.6]
Average knee pain score improvement	3.5	3.9	diff -0.4, 95%CI [-1.3 to 0.5]

Findings: In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after meniscal repair were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from meniscal repair.

STUDY
FIDELITY Post hoc Analysis of Patients with Mechanical Symptoms, Ann Intern Med (2016) [PubMed abstract]

A post hoc analysis on data from the FIDELITY study was published in the Annals of Internal Medicine in 2016
The analysis compared outcomes among the subgroup of patients in the trial who reported mechanical symptoms (defined as sensations of knee catching or locking)
During the one-year follow-up period, 49% of patients in the surgery group and 43% of patients in the sham group reported having mechanical symptoms at least once
In the subgroup of 69 patients who reported mechanical symptoms before surgery, 72% (23/32) in the surgery group and 59% (22/37) in the sham group reported mechanical symptoms at least once during follow-up

Findings: Resection of a torn meniscus has no added benefit over sham surgery to relieve knee catching or occasional locking. These findings question whether mechanical symptoms are caused by a degenerative meniscus tear and prompt caution in using patients' self-report of these symptoms as an indication for meniscal repair.

DREAM Study - Early Surgery vs Physical Therapy for Meniscal Tear in Young Adults, NEJM Evidence (2022) [NEJM Evidence]

The DREAM study enrolled 121 young adults with meniscal tears

Main inclusion criteria

Age 18 - 40 years
History and symptoms consistent with meniscal tear
Meniscal tear confirmed on MRI

Main exclusion criteria

Prior surgery on affected knee
Displaced bucket handle tear confirmed by MRI
Complete rupture of any knee ligament

Baseline characteristics

Average age 29 years
Male sex - 72%
Mean BMI - 26
Symptom duration of 0 to 6 months - 57%
Semi-traumatic or traumatic onset - 73%
Knee catching or locking - 53%
Previous moderate to high activity level - 74%

Randomized treatment groups

Group 1 (60 patients): Arthroscopic partial meniscectomy or meniscal repair
Group 2 (61 patients): Supervised exercise therapy and education for 12 weeks

Primary outcome: Between-group difference in change in Knee Injury and Osteoarthritis Outcome Score (KOOS4) from baseline to 12 months. KOOS4 scores range from 0 to 100, with lower scores indicating worse symptoms, function, and quality of life.

Results

Outcome	Surgery	PT	Comparisons
Duration: 12 months
Primary outcome (KOOS4 improvement)	+19.2	+16.4	Diff 5.4, 95%CI [-0.7 to 11.4]
Crossovers	13%	26%	N/A
Per-protocol and as-treated analyses yielded similar results There was no difference in serious adverse events (surgery - 4 events; PT - 7 events, p=0.40)

Findings: Our results suggest that among young, active adults with meniscal tears, a strategy of early meniscal surgery is not superior to a strategy of exercise and education with the option of later surgery. Both groups experienced clinically relevant improvements in pain, function, and quality of life at 12 months, and one of four from the exercise group eventually had surgery.

Meniscectomy vs Physical Therapy in Patients with Meniscal Tear and OA, NEJM (2013) [PubMed abstract]

The trial enrolled 351 patients with a symptomatic meniscal tear and osteoarthritis

Main inclusion criteria

One month of meniscal tear symptoms (defined as at least one of the following: clicking, catching, popping, giving way, pain with pivot or torque, episodic pain, pain that is acute and localized to one joint line)
Age ≥ 45 years
Evidence of mild-to-moderate osteoarthritis on X-ray or MRI
Meniscal tear on MRI

Main exclusion criteria

Severe osteoarthritis
Locked knee

Baseline characteristics

Average age 58 years
Average BMI - 30
Average baseline WOMAC score - 37
OA severity: None - 21% | Possible OA - 18% | Mild - 23% | Moderate - 26%

Randomized treatment groups

Group 1 (161 patients): Partial meniscectomy followed by physical therapy
Group 2 (169 patients): Physical therapy with option for later surgical meniscal repair if needed

Primary outcome: Difference between groups in change in score from baseline on the WOMAC Index (ranging from 0 to 100, with higher scores indicating more severe symptoms) at 6 months

Results

Outcome	Meniscectomy	Physical therapy	Comparisons
Duration: 12 months
Change in WOMAC at 6 months	20.9	18.5	diff 2.4, 95%CI [-1.8 to 6.5]
Change in WOMAC at 12 months	23.5	22.8	diff 0.7, 95%CI [-3.5 to 4.9]
There was no significant difference in pain scores between the two groups In the physical therapy group, 30% of the patients had surgery (crossovers) at 6 months, and 35% by 12 months In the surgery group, 5.6% of patients had not undergone surgery by 6 months An as-treated analysis found no difference between the two groups at 6 and 12 months

Findings: In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months.

Summary

In the three studies above, surgical meniscectomy or repair was no better than physical therapy for various pain and function outcomes. The most compelling study is the FIDELITY study, where patients were blinded to their assigned treatment. The other two studies also found no benefit of surgery in two diverse populations - older patients with OA and active young adults. Crossover rates in these studies were 25 - 35%, which can bias results towards the null in intention-to-treat analyses. It's reassuring that per-protocol and as-treated analyses also found no difference, but these methods have their own weaknesses.
Does meniscal surgery offer some benefit in a small subgroup of patients (e.g. elite athletes)? It's possible, but the vast majority of people should avoid this procedure. Despite these negative studies, meniscal surgery continues to be a common procedure.

KNEE OA | Steroid injections

Osteoarthritis of the knee

Osteoarthritis (OA) is the form of arthritis that develops as people age. It occurs from the natural "wear and tear" on joints over time. Because of this, it is usually seen in patients ≥ 50 years, but it may also occur in younger patients who have a history of joint trauma or genetic predisposition.
Knee OA is the most common form of OA. The pain of knee OA typically develops gradually and worsens over time. If all the cartilage in the knee wears away (bone-on-bone), then a knee replacement may be necessary to relieve the pain.

Steroid injections for knee OA

A common treatment for knee OA is to inject steroids into the knee joint. Theoretically, steroids suppress inflammation and improve knee symptoms. While this treatment is widespread, well-done placebo-controlled trials have mostly found it to be of no benefit.

Steroid Injection vs Placebo Injection for Knee OA, JAMA Internal Medicine (2015) [PubMed abstract]

A JAMA Internal Medicine trial enrolled 100 patients with knee OA

Main inclusion criteria

Age ≥ 40 years
Radiographic confirmation of clinical OA of the knee
Clinical signs of localized inflammation in the knee
Knee pain during walking (score > 4 on a scale of 0 - 10 with 10 being the worst)
BMI ≤ 35

Main exclusion criteria

Steroid injection or exercise therapy within 3 months
Oral steroids within 4 weeks
Inflammatory arthritis
Fibromyalgia
Spinal nerve root compression

Baseline characteristics

Average age 63 years
Female - 61%
Average BMI - 29
Average KOOS pain subscale score - 54
Average KOOS function score - 62
OA grade on X-ray: Possible - 4% | Mild - 39% | Moderate - 32% | Severe - 25%

Randomized treatment groups

Group 1 (50 patients): Knee injection of saline mixed with 4 ml of lidocaine
Group 2 (50 patients): Knee injection of methylprednisolone 40 mg mixed in 4 ml of lidocaine
Patients in both groups started a 12-week supervised exercise program 2 weeks after the injection

Primary outcome: Change from baseline in the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (range 0 - 100, higher scores indicate less pain) at Week 14

Results

Outcome	Saline	Steroid	Comparisons
Duration: 14 weeks
Primary outcome (change in KOOS score at Week 14)	14.8	13.6	diff 1.2, 95%CI [-3.8 to 6.2], p=0.64
Change in KOOS pain score at Week 2	4.5	5.0	diff -0.5, 95%CI [-5.5 to 4.5], p=0.85
Number of squats in 30 seconds at Week 14	9.0	6.6	diff 2.4, 95%CI [-1.5 to 6.2], p=0.23
Change in KOOS function score at Week 14	15	14.9	diff 0.1, 95%CI [-4.6 to 4.8], p=0.96
Patients also had MRIs performed at baseline and Week 14. There was no significant difference in MRI-assessed synovitis between the groups.

Findings: No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee. Further research is needed to establish optimal and potentially synergistic combinations of conservative treatments.

Steroid Injections vs Saline Injections every 3 Months for 2 years for Knee OA, JAMA (2017) [PubMed abstract]

A JAMA trial enrolled 140 patients with knee OA

Main inclusion criteria

Age ≥ 45 years
OA based on American College of Rheumatology criteria (knee pain with evidence of OA on X-ray)
Ultrasound evidence of effusion synovitis in the study knee

Main exclusion criteria

Other systemic inflammatory joint disease
Chronic or recent use of oral corticosteroids, doxycycline, indomethacin, glucosamine, or chondroitin
Recent (<3 months) intraarticular corticosteroids or hyaluronic acid

Baseline characteristics

Average age 58 years
Female - 53%
Average BMI - 31
Average WOMAC pain score - 8.3
Average WOMAC function scale - 29

Randomized treatment groups

Group 1 (70 patients): Knee injection of triamcinolone 40 mg every 12 weeks for 2 years
Group 2 (70 patients): Knee injection of saline every 12 weeks for 2 years
Local anesthetic was not used with injections
Participants were advised to take acetaminophen only if needed
Participants were asked to discontinue concomitant analgesics 2 days before each assessment to avoid masking symptoms of pain

Primary outcomes:

1. Annual knee magnetic resonance imaging for quantitative evaluation of cartilage volume
2. Western Ontario and McMaster Universities (WOMAC) Osteoarthritis index collected every 3 months (Likert pain subscale range, 0 [no pain] to 20 [extreme pain])

Results

Outcome	Steroid	Saline	Comparisons
Duration: 2 years
Change in average cartilage thickness	-0.29 mm	-0.13 mm	diff 0.16 mm, 95%CI [-0.31 to -0.01], p=0.04
Change in WOMAC pain score	-1.2	-1.9	diff 0.64, 95%CI [-1.6 to 0.29], p=0.17
Change in WOMAC function score	-4.1	-5.1	diff 1.01, 95%CI [-4.9 to 2.9], p=0.59
There was no significant difference in new or worsening hypertension between the groups Hemoglobin A1C levels declined in the triamcinolone but increased in the saline group (−0.1% vs 0.2%; between-group difference, −0.2; 95%CI [−0.5 to −0.007])

Findings: Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.

Steroid Injections vs Physical Therapy for Knee OA, NEJM 2020 [PubMed abstract]

The study enrolled 156 patients with knee OA

Main inclusion criteria

Age ≥ 38 years
Meet ACR criteria for knee OA
Evidence of OA on X-ray

Main exclusion criteria

PT or steroid shot within 12 months
No evidence of OA on X-ray
History of gout in the knee
History of rheumatoid arthritis

Baseline characteristics

Average age 56 years
Female sex - 48%
Average BMI - 31.5
Average duration of symptoms - 7.6 years
Average WOMAC score - 108
Kellgren–Lawrence grade: 1 - 3.8% | 2 - 43.6% | 3 - 37.8% | 4 - 14.7%

Randomized treatment groups

Group 1 (78 patients): Steroid injections
Group 2 (78 patients): Physical therapy
In the steroid group, patients could receive up to 3 injections over the 1-year trial period
Steroid injections included 40 mg of triamcinolone and 7 mls of lidocaine 1%
In the PT group, patients underwent up to 8 treatment sessions over the initial 4-to-6-week period; the patient could attend an additional 1 to 3 sessions at the time of the 4-month and 9-month reassessments if that plan of care was agreed on by the physical therapist and the patient

Primary outcome: Total WOMAC score (range 0 - 240 with higher scores being worse) at 1 year

Results

Outcome	Steroid	PT	Comparisons
Duration: 1 year
Average baseline total WOMAC score	108	107	N/A
Primary outcome (WOMAC at 1 year)	55.8	37	p=0.008
In the Steroid group, patients received an average of 2.6 injections over the course of the trial In the PT group, 9% of patients also received a steroid injection. In the Steroid group, 18% of patients also received physical therapy.

Findings: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection.

2021 AAOS recommendation

Intra-articular corticosteroids could provide short-term relief for patients with symptomatic osteoarthritis of the knee [1]

Summary

In the trials above, steroid injections were no better than placebo and inferior to physical therapy for knee OA. Prolonged injections (> 1 year) may lead to faster cartilage deterioration.
While popular, steroid injections have mostly fallen flat in randomized, placebo-controlled trials. Conscientious patients and providers should largely avoid their use.

KNEE OA | Hyaluronic acid injections

Overview

A popular treatment for knee OA is the injection of hyaluronic acid (Synvisc®) into the knee joint. Hyaluronic acid is a gel-like substance that is supposed to "lubricate and cushion" the knee joint. A study published in The Journal of Bone and Joint Surgery that compared hyaluronic acid to steroid injections is presented below.

Hyaluronic Acid Injection (Synvisc-One®) vs Steroid Injections for Knee OA, The Journal of Bone and Joint Surgery (2016) [PubMed abstract]

A study in The Journal of Bone and Joint Surgery enrolled 99 patients with knee OA

Main inclusion criteria

Symptomatic knee OA according to American Rheumatism Association classification criteria
Dissatisfaction with conservative treatment (NSAIDs, oral analgesic drugs, physical therapy, or brace)

Main exclusion criteria

Lumbar spondylosis with radiculopathy
Bone-on-bone arthritis on X-ray
Varus or valgus deformity > 5°
Previous fracture or surgery on affected knee
Injection of affected knee within 6 months

Baseline characteristics

Average age 62 years
Average BMI - 26
Average pain visual analog score - 52
Average WOMAC score - 41
Average knee flexion - 125°
OA grade on X-ray: Possible OA - 22% | Mild - 22% | Moderate - 41% | Severe - 14%

Randomized treatment groups

Group 1 (50 patients): Knee injection of 6 ml of Hylan G-F 20 (Synvisc-One®)
Group 2 (49 patients): Knee injection of triamcinolone 40 mg mixed in 5 ml of 1% lidocaine with epinephrine
If knee effusion was present, it was aspirated at the time of injection

Primary outcome: Knee pain (assessed with visual analog scale, range 0 - 100 with higher number being worse pain), knee function (assessed with WOMAC index, range 0 - 96 with higher numbers being worse function), and knee range of motion at 6 months

Results

Outcome	Synvisc	Steroid	Comparisons
Duration: 6 months
Primary outcome (pain score at 6 months)	24	21	diff 3, 95%CI [-6 to 11], p=0.60
Primary outcome (WOMAC score at 6 months)	21	21	diff 0, 95%CI [-8 to 6], p=0.81
Primary outcome (knee flexion at 6 months)	132°	133°	diff -1, 95%CI [-5 to 2], p=0.43
Primary outcome (pain score at 1 week)	23	14	diff 9, 95%CI [1 to 15], p=0.018

Findings: Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week.

2021 AAOS recommendation

Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee [1]

Summary

In the study above, Synvisc-One® was no better than a steroid injection for knee pain and function at 6 months. Steroid injection was significantly better than Synvisc-One® for pain relief up to 1 week.
Perhaps the most important difference is the following: Synvisc-One® ∼ $1000; 40 mg vial of triamcinolone ∼ $10

KNEE OA | Platelet-rich plasma

Overview

Platelet-rich plasma is a product made by taking blood from a patient and centrifuging it to separate the red blood cells, platelets, and plasma into different layers. The platelet layer is removed and mixed with a small amount of plasma to produce platelet-rich plasma. The sample is sometimes treated with chemicals to make the platelets lyse and release growth factors. Proponents of this therapy contend that bloodborne cytokines and growth factors stimulate and accelerate healing. The procedure has received some notoriety from professional athletes, but it is not widely accepted by mainstream medicine.

STUDY
Platelet-rich Plasma (PRP) Injections vs Placebo Injections for Knee OA, JAMA (2021) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=288 | length = 12 months) in patients with symptomatic knee OA and mild to moderate radiographic tibiofemoral OA
Treatment: PRP injections once weekly for 3 weeks vs Placebo injections (normal saline)
Primary outcome: The 2 primary outcomes were 12-month change in knee pain (scale: 0 (no pain) to 10 (worst pain)) and 12-month percentage change in MRI-measured medial tibial cartilage volume, respectively
Results:

Primary outcome (change in knee pain score): PRP -2.1, Placebo -1.8 (p=0.17)
Primary outcome (change in medial tibial cartilage): PRP -1.4%, Placebo -1.2% (p=0.81)

Findings: Among patients with symptomatic mild to moderate radiographic knee OA, intra-articular injection of PRP, compared with injection of saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months. These findings do not support use of PRP for the management of knee OA.

2021 AAOS recommendations

Platelet-rich plasma (PRP) may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee [1]

Summary

This is yet another study that found PRP injections have no effect on joint and tendon disorders. PRP injections have resoundingly failed in placebo-controlled trials and should not be recommended.

KNEE OA | Chondroitin/Glucosamine

Overview

The dietary supplements glucosamine and chondroitin are often taken by people to treat knee pain. Chondroitin is a glycosaminoglycan, a major component of cartilage, and glucosamine is an amino sugar that serves as a precursor for glycosaminoglycan. These properties are used to promote their theoretical effect in treating OA.
Three trials that compared glucosamine/chondroitin to placebo for knee OA are presented below

STUDY
Pharmaceutical-grade Chondroitin Sulfate vs Celecoxib vs Placebo for Knee Osteoarthritis, BMJ (2017) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=604 | duration=6 months)
Treatment: Pharmaceutical-grade Chondroitin 800 mg once daily vs Celecoxib 200 mg once daily vs Placebo
Primary outcome: Change in pain on a 100 mm Visual Analogue Scale (VAS) and change in the Lequesne Index at 6 months
Results:

Primary outcome (VAS): Chondroitin -42.6, Celecoxib -39.5, Placebo -33.3 (p<0.05 for chondroitin or celecoxib vs placebo)
Primary outcome (Lequesne Index): Chondroitin -4.7, Celecoxib -4.6, Placebo -3.7 (p<0.05 for chondroitin or celecoxib vs placebo)

Findings: A 800 mg/day pharmaceutical-grade chondroitin sulfate is superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in symptomatic knee osteoarthritis patients. This formulation of chondroitin should be considered a first-line treatment in the medical management of knee OA.

STUDY
Chondroitin Sulfate + Glucosamine Sulfate vs Placebo for Knee Osteoarthritis, Arthritis and Rheumatology (2017) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=164 | duration=6 months)
Treatment: Chondroitin 1200 mg + Glucosamine 1500 once daily (CG) vs Placebo
Primary outcome: Mean change from baseline in the VAS global pain score (0 - 100 with 100 being greatest pain and 0 being no pain)
Results:

Primary outcome (VAS): CG -11.8, Placebo -20.5 (p<0.03, placebo superior)

Findings: The results of this trial demonstrate a lack of superiority of CS/GS combination therapy over placebo in terms of reducing joint pain and functional impairment in patients with symptomatic knee OA over 6 months. Further research might fully elucidate the suitability of CS/GS combination therapy in patients with OA

STUDY
Glucosamine vs Chondroitin vs Chondroitin/Glucosamine vs Celecoxib vs Placebo for Knee Osteoarthritis - NEJM (2006) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=1583 | duration=24 weeks)
Treatment: Chondroitin 1200 mg (C) vs Glucosamine 1500 (G) vs Chondroitin/Glucosamine combined (CG) vs Celecoxib 200 mg once daily vs Placebo
Primary outcome: Proportion of patients with 20% decrease in knee pain from baseline to week 24
Results:

Primary outcome: C - 65.4%, G - 64%, CG - 66.6%, Celecoxib - 70.1%, Placebo - 60.1% (compared to placebo, only celecoxib was significantly better p=0.008)

Findings: Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain.

2021 AAOS recommendation

Glucosamine or chondroitin may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis; however, the evidence is inconsistent/limited and additional research is needed [1]

KNEE OA | Turmeric

Overview

Turmeric, also known as Curcuma longa, is a flowering plant of the ginger family. It is widely available as a dietary supplement and is touted as having antiinflammatory properties. A small study published in 2020 compared tumeric to placebo in knee OA.

STUDY
Turmeric vs Placebo for Knee OA Symptoms and Effusion–Synovitis, Ann Intern Med (2020) [PubMed abstract]

Design: Randomized placebo-controlled trial (N=70 | length = 12 weeks) in patients with knee OA and ultrasonography-defined effusion-synovitis
Treatment: Turmeric 1000 mg daily vs Placebo
Primary outcomes: Changes in knee pain on a visual analogue scale (0 - 100 mm with 100 being worst) and effusion-synovitis volume on MRI
Results:

Primary outcome (decrease in knee pain scale): Turmeric - 24 mm, Placebo - 15 mm (p=0.039)
Primary outcome (effusion-synovitis): There was no significant difference in effusion-synovitis volume

Findings: Turmeric was more effective than placebo for knee pain but did not affect knee effusion-synovitis or cartilage composition. Multicenter trials with larger sample sizes are needed to assess the clinical significance of these findings.

2021 AAOS recommendation

Tumeric may be helpful in reducing pain and improving function for patients with mild to moderate knee osteoarthritis; however, the evidence is inconsistent/limited and additional research is needed [1]

KNEE | Knee replacement studies

Overview

Knee replacement surgery is a common treatment for severe knee OA
There are three forms of knee replacement surgery. In a total knee replacement (TKR), all articular surfaces of the tibia and fibula are replaced (see TKR illustration). In a unicompartmental knee replacement (UKR) which is also called a partial knee replacement (PKR), only one side of the knee is replaced (see UKR illustration). In a patellofemoral replacement (PFR), only the groove in the femur where the patella slides is replaced (see PFR illustration).
The first study detailed below compared TKR to PKR in patients with isolated osteoarthritis of the medial compartment of the knee. The second study looked at the durability of knee replacements over time.

STUDY
Total vs Partial Knee Replacement for Isolated Medial Compartment OA, Lancet (2019) [PubMed abstract]

Design: Randomized controlled trial (N=528 | length = 5 years) in patients with isolated osteoarthritis of the medial compartment of the knee
Treatment: Total knee replacement (TKR) vs Partial knee replacement (PKR)
Primary outcome: Oxford Knee Score (range 0 - 48 with higher scores being better) at 5 years
Results:

Primary outcome: TKR - 37, PKR - 38 (p=0.159)
Re-operations (as-treated analysis): TKR - 8%, PKR - 6%
Received other treatment (crossovers): TKR - 5%, PKR - 12%

Findings: Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis.

STUDY
Durability of Knee Replacement, Lancet (2017) [PubMed abstract]

A study published in the Lancet in 2017 looked at the risk of revision surgery among 54,276 patients who had undergone a total knee replacement
Average age of the cohort at time of surgery was 70 years

^✝Data from **PMID 30782341**
Total knee replacement durability
Years since replacement	Original implant still in place
5	98%
10	95%
15	91%
20	86%
25	82%^✝
Initial age of surgery	Lifetime risk of revision
50 - 54	Men - 35% Women - 20%
60	15%
> 70 years	5%
Other Average age of cohort at replacement was 70 years except for 25-year data where average age was 68 years Women had an overall lower risk of revision surgery The risk for revision surgery was greatest in the first five years after the original surgery ^✝The 25-year survival for a UKR was 70%

ANKLE | Osteoarthritis

STUDY
Platelet-Rich Plasma Injections vs Placebo for Ankle Osteoarthritis, JAMA (2021) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=100 | length = 26 weeks) in adults with ankle osteoarthritis
Treatment: Two ultrasound-guided intra-articular injections 6 weeks apart with platelet-rich plasma or placebo
Primary outcome: Change in American Orthopaedic Foot and Ankle Society (AOFAS) score over 26 weeks of follow-up (range, 0-100 points; higher scores indicate less pain and better function)
Results:

Baseline AOFAS score: Platelet-rich plasma - 63, Placebo - 64
Primary outcome: Platelet-rich plasma +10 points, Placebo +11 points (p=0.56)

Findings: Among patients with ankle osteoarthritis, intra-articular Platelet-rich plasma injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of platelet-rich plasma injections for ankle osteoarthritis.

FOOT | Plantar fasciitis

Plantar fasciitis

Plantar fasciitis is the most common cause of heel pain affecting up to 7% of the general population. It is also a common cause of heel pain in runners.
The plantar fascia is a thick band of connective tissue that transverses the bottom of the foot and provides support to the arch of the foot
The plantar fascia connects to the calcaneus (heel bone) at one end and to the heads of the metatarsal bones at the other end (plantar fascia image)
Plantar fasciitis is a condition that causes intense heel pain with weight-bearing at the calcaneal insertion site of the plantar fascia
The exact cause of plantar fasciitis is unknown. The condition is typically self-limited, and in most patients, symptoms will resolve within 12 months regardless of treatment.
A popular treatment for plantar fasciitis is to inject steroids around the plantar fascia insertion site at the calcaneus

Steroid Injection vs Placebo Injection for Plantar Fasciitis, BMJ (2012) [PubMed abstract]

A study in the British Medical Journal enrolled 82 patients with plantar fasciitis

Main inclusion criteria

Inferior heel pain for ≥ 8 weeks
Plantar fascia thickness of ≥ 4 mm on ultrasound (indicator of inflammation)

Main exclusion criteria

Steroid injection for plantar fasciitis within previous 6 months
Diabetes
History of trauma to heel
Other therapy for plantar fasciitis within 4 weeks

Baseline characteristics

Average age 52 years
Average BMI 31
Median duration of symptoms: Steroid group - 9 months | Placebo group - 12 months
Bilateral plantar fasciitis - 29%

Randomized treatment groups

Group 1 (41 patients): Ultrasound-guided steroid injection of plantar fascia (4 mg of dexamethasone)
Group 2 (41 patients): Ultrasound-guided placebo injection

Primary outcome: Pain and plantar fascia thickness at 4, 8, and 12 weeks. Pain was measured by the foot pain domain of the foot health status questionnaire. This instrument has four domains (pain, function, footwear, and general foot health), with each scored on a 0 - 100 point scale, where 0 represents the worst foot health and 100 the best foot health.

Results

Outcome	Steroid	Placebo	Comparisons
Duration: 12 weeks
Baseline foot health status score	37	36	N/A
Foot health status score (4 weeks)	59	48	diff 10.9 95%CI [1.4 - 20.4], p=0.03
Foot health status score (8 weeks)	62	56	diff 5.6 95%CI [-4.5 to 15.6], p=0.28
Foot health status score (12 weeks)	65	60	diff 5 95%CI [-5.7 to 16.3], p=0.34
Plantar fascia thickness was significantly less in the steroid group at all 3 time points

Findings: A single ultrasound guided dexamethasone injection is a safe and effective short term treatment for plantar fasciitis. It provides greater pain relief than placebo at four weeks and reduces abnormal swelling of the plantar fascia for up to three months. However, clinicians offering this treatment should also note that significant pain relief did not continue beyond four weeks.

Summary

Based on this well-done study, most patients with plantar fasciitis can expect about 4 weeks of significant relief with a steroid injection. Beyond that, injections do not appear to be any better than placebo. This short-term effect may be from systemic absorption of the steroid as opposed to steroid placement.
Serious adverse events associated with plantar fasciitis injections include plantar fascia rupture and plantar fat pad atrophy. The frequency of these events is not well-defined in the medical literature.
In this study, injections were done under ultrasound guidance which may have improved their overall efficacy and safety when compared to real-world scenarios where most injections are done without ultrasound guidance
In short, plantar fasciitis is typically a self-limited condition that resolves without intervention in most patients within one year. Patients may receive short-term relief (4 weeks) from steroid injections while assuming risks that are not well-defined.

FOOT | Achilles rupture

Overview

The Achilles tendon connects the calf muscle to the heel bone. Achilles tendon rupture (Achilles rupture illustration) typically occurs in middle-aged adults (mean age of 37 - 44 years) during recreational activities. Symptoms of Achilles rupture include a sudden, painful popping sensation in the back of the lower leg accompanied by an inability to "push off" with the foot.
In the past, Achilles rupture was often treated with surgery, but studies have shown that nonoperative treatment is just as effective. A randomized controlled trial that found no difference between nonoperative treatment and surgery is detailed below (surgery vs none). In addition, a meta-analysis comparing operative to nonoperative treatment found that surgery reduced the risk of re-rupture by about 1.6% but increased the risk of complications (primarily infections) by 3.3%. [PMID 30617123]
Patients treated nonoperatively often receive serial casting that slowly changes the position of the foot until the heel is flat on the floor. This treatment can be cumbersome and time-consuming. A study that compared serial casting to a removable functional brace is summarized below (Achilles casting vs bracing). A third study that looked at the effects of platelet-rich plasma on healing times is also reviewed (PRP for Achilles rupture).

Surgery vs Nonoperative Treatment for Acute Achilles Tendon Rupture, NEJM (2022) [PubMed abstract]

The trial enrolled 554 Norwegian adults with acute Achilles tendon rupture

Main inclusion criteria

Age 18 - 60 years
Acute Achilles tendon rupture

Main exclusion criteria

Quinolones within last 6 months
Achilles steroid injection within last 6 months
Dependence on walking aids

Baseline characteristics

Average age 39 years
Male sex - 73%
Average BMI - 27
Baseline ATRS - 93

Randomized treatment groups

Group 1 (178 patients): Nonoperative treatment
Group 2 (176 patients): Open surgical repair
Group 3 (172 patients): Minimally invasive (MI) surgical repair
A below-the-knee equinus cast (with plantar flexion) was applied within 72 hours after the injury regardless of the treatment group assignment. The cast was maintained for 2 weeks after application in the nonoperative group; in the surgical groups, a new cast was applied after surgery and maintained for 2 weeks. For 6 weeks after the cast was removed, patients were allowed to bear weight on the injured foot as tolerated using an ankle–foot orthosis with heel wedges. The number of heel wedges was gradually reduced from three in the first week of orthosis treatment to none in the last week.
All patients underwent a standard physical therapy protocol

Primary outcome: Change from baseline in the Achilles’ tendon Total Rupture Score (ATRS) at the 12-month follow-up. ATRS ranges from 0 to 100, with higher scores indicating better health status. Baseline scores were obtained at enrollment by having participants answer questionnaires based on their preinjury status.

Results

Outcome	Nonoperative	Open surgery	MI surgery	Comparisons
Duration: 12 months
Primary outcome (12 months)	-17	-16	-14.7	p=0.57
Primary outcome (3 months)	-45.9	-43.1	-49.8	N/A
Primary outcome (6 months)	-28.8	-28	-31.2	N/A
Tendon re-rupture	6.2%	0.6%	0.6%	N/A
Nerve injury	0.6%	2.8%	5.2%	N/A
Average baseline ATRS across all groups was 93

Findings: In patients with Achilles' tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months.

STUDY
Serial Plaster Casting vs Removable Functional Brace for Achilles Tendon Rupture, Lancet (2020) [PubMed abstract]

Design: Randomized controlled trial (N=540 | length = 9 months) in patients with acute Achilles tendon rupture
Treatment: Serial casting vs Functional brace. Both treatments were given for 8 weeks.
Primary outcome: Patient-reported Achilles tendon rupture score (range 0 - 100 with 100 being best outcome) at 9 months
Results:

Primary outcome: Cast - 74.4, Brace - 72.8 (p=0.44)
Achilles re-rupture: Cast - 6%, Brace - 5% (p=0.40)

Findings: Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by Achilles tendon rupture score, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting.

STUDY
Platelet-rich Plasma Injection vs Sham injection for Acute Achilles Tendon Rupture, BMJ (2019) [PubMed abstract]

Design: Randomized, placebo-controlled trial (N=230 | length = 24 weeks) in patients with acute Achilles tendon rupture
Treatment: Autologous platelet-rich injection in tendon gap vs Sham injection. All patients were being treated nonsurgically with a cast, splint, or boot.
Primary outcome: Muscle tendon function as measured by the validated heel rise endurance test at 24 weeks
Results:

No difference was detected in muscle tendon function between participants receiving platelet-rich plasma injections and those receiving placebo injections or in any secondary outcomes or adverse event rates

Findings: There is no evidence to indicate that injections of platelet-rich plasma can improve objective muscle tendon function, patient reported function, or quality of life after acute Achilles tendon rupture compared with placebo, or that they offer any patient benefit.

FOOT | Achilles tendonitis

Overview

The Achilles tendon connects the calf muscle to the heel bone (Achilles tendon image). Overuse can cause the tendon to become inflamed, and Achilles tendonitis is typically seen in runners and middle-aged people who play sports.
A treatment that is sometimes used involves injecting the patient's own blood or blood components around the inflamed tendon. Proponents of this therapy contend that bloodborne cytokines and growth factors stimulate and accelerate healing. The procedure has received some notoriety from professional athletes, but it is not widely accepted by mainstream medicine.
A study that compared autologous blood injections to sham injections is detailed below along with a similar study that looked at platelet-rich plasma

Autologous Blood Injection vs Sham Injection for Achilles Tendonitis, BMJ (2013) [PubMed abstract]

A study in the British Medical Journal enrolled 53 patients with Achilles tendonitis

Main inclusion criteria

Symptoms of unilateral mid-portion Achilles tendinopathy for ≥ 3 months
Diagnosis confirmed by ultrasound

Main exclusion criteria

Bilateral symptoms
Previous Achilles rupture or surgery
Previous adjuvant therapy

Baseline characteristics

Average age 48 years
Average duration of symptoms: Treatment group - 23 months | Control - 39 months
Moderate changes on US: Treatment group - 62% | Control - 63%
Severe changes on US: Treatment group - 19% | Control - 4%

Randomized treatment groups

Group 1 (26 patients): Two injections (one month apart) of patient's own blood (3 ml) into site of maximal Achilles' tenderness
Group 2 (27 patients): Two placebo injections 1 month apart
All participants were instructed to do 180 heel drops over a step each day. Subjects were allowed to exercise as long as it did not induce pain.

Primary outcome: Change in the Victorian Institute of Sports Assessment-Achilles (VISA-A) score measured at baseline and again at one, two, three, and six months. Scores range from 0-100 with 100 indicating a symptom-free tendon.

Results

Outcome	Blood	Placebo	Comparisons
Duration: 6 months
Baseline score	58	57	N/A
Change in VISA-A (one month)	+7.9	+5.3	diff 2.6, 95%CI [−3.4 to 8.6]
Change in VISA-A (two months)	+12	+8.6	diff 3.4, 95%CI [−3.8 to 11]
Change in VISA-A (three months)	+15.2	+14.9	diff 0.3, 95%CI [−6.9 to 7.5]
Change in VISA-A (six months)	+18.7	+19.9	diff -1.2, 95% CI [−10 to 7.9]

Findings: The administration of two unguided peritendinous autologous blood injections one month apart, in addition to a standardised eccentric training programme, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy.

STUDY
Platelet-rich Plasma Injection vs Sham Injection in Midportion Achilles Tendinopathy, JAMA (2021) [PubMed abstract]

Design: Randomized, sham-controlled trial (N=240 | length = 6 months) in adults with pain at the midportion of the Achilles tendon for longer than 3 months and tendinopathy confirmed by ultrasound, MRI, or both
Treatment: Platelet-rich plasma injection vs Sham injection. All participants were asked to avoid additional treatments and were advised to return to normal activities when they felt able, while avoiding significant activity (e.g. running or weight training) for 1 week.
Primary outcome: The Victorian Institute of Sport Assessment-Achilles score (VISA-A) at 6 months (range, 0 [worst symptoms] to 100 [no symptoms]; minimal clinically important difference in score, 12 points)
Results:

Baseline VISA-A score: Platelet-rich plasma - 37.6, Sham - 33.2
Primary outcome: Platelet-rich plasma - 54.4, Sham - 53.4 (p=0.76)

Findings: Among patients with chronic midportion Achilles tendinopathy, treatment with a single injection of intratendinous platelet-rich plasma, compared with insertion of a subcutaneous dry needle, did not reduce Achilles tendon dysfunction at 6 months. These findings do not support the use of this treatment for chronic midportion Achilles tendinopathy

Summary

Neither autologous blood nor platelet-rich plasma injections had a beneficial effect on Achilles tendonitis in the two studies detailed above
In general, all types of tendonitis are difficult to treat. While a number of therapies have been proposed, time appears to be more effective than anything.

SHOULDER | Rotator cuff tear

Overview

The rotator cuff is a group of tendons that connect to the head of the humerus. The tendons originate from muscles on the scapula, and they combine to provide stability and motion to the shoulder joint. See rotator cuff illustration.
As people age, tears may develop in the rotator cuff tendons. In some studies, up to 30% of the population ≥ 60 years old have rotator cuff tears.
Nontraumatic rotator cuff tears typically originate in the supraspinatus tendon underneath the acromion. There are several hypotheses as to why this occurs. Under one theory, the tear occurs secondary to chronic friction between the supraspinatus tendon and acromion. This theory serves as a basis for acromioplasty, a surgical procedure where the bottom of the acromion is shaved off to increase the space between the acromion and the tendon. Other theories suggest that the tear is unrelated to mechanical factors and most likely due to tendon degeneration over time.

PT vs Acromioplasty vs Rotator Cuff Repair + Acromioplasty for Symptomatic Supraspinatus Tear, J Bone Joint Surg (2015) [PubMed abstract]

A study in the The Journal of Bone and Joint Surgery enrolled 180 shoulders with nontraumatic, symptomatic, supraspinatus tears

Main inclusion criteria

Age ≥ 55 years
Nontraumatic, symptomatic, isolated full-thickness supraspinatus tendon tear documented with MRI
Full range of motion in shoulder

Main exclusion criteria

Tear involving entire tendon
Tears of other tendons
Glenohumeral osteoarthritis visible on X-ray

Baseline characteristics

Average age 65 years
Average duration of symptoms - 27 months

Randomized treatment groups

Group 1 (60 patients): Physical therapy that included written instructions and 10 monitored sessions (PT group)
Group 2 (60 patients): Acromioplasty + physical therapy (A/PT group)
Group 3 (60 patients): Acromioplasty + supraspinatus repair + physical therapy (A/R/PT group)

Primary outcome: Change in the absolute Constant score at 2 years. The Constant score is the sum of four subscores (pain, activities of daily living, range of motion, and strength). Higher scores mean less pain and better function. Scale goes from 0 (worst) to 100 (best).

Results

Outcome	PT	A/PT	A/R/PT	Comparisons
Duration: 2 years
Baseline Constant score	58	60	58	N/A
Primary outcome	+18.4	+20.5	+22.6	p=0.38 for difference between groups
There was no significant difference between the groups in the visual analog scale for pain (p=0.45) Patients satisfaction was high in all 3 groups (PT - 89%, A/PT - 95%, A/R/PT - 94%) Five patients crossed over from the PT group to surgical treatment Average change in supraspinatus tear on MRI from baseline to 2 years was smaller in the A/R/PT group (PT group: 9.6 mm at baseline to 10.4 mm at 2 years \| A/PT group: 9.1 mm at baseline to 11.7 mm at 2 years \| A/R/PT group: 8.4 mm at baseline to 4.2 mm at 2 years)

Findings: There was no significant difference in clinical outcome between the three interventions at the two-year follow-up. The potential progression of the rotator cuff tear, especially in the non-repaired treatment groups, warrants further follow-up. On the basis of our findings, conservative treatment is a reasonable option for the primary initial treatment for isolated, symptomatic, nontraumatic, supraspinatus tears in older patients.

2019 AAOS recommendations

Strong evidence supports that both physical therapy and operative treatment result in significant improvement in patient-reported outcomes for patients with symptomatic small to medium full-thickness rotator cuff tears.
Strong evidence supports that patient reported outcomes improve with physical therapy in symptomatic patients with full thickness rotator cuff tears. However, the rotator cuff tear size, muscle atrophy, and fatty infiltration may progress over 5 to 10 years with non operative management
Moderate evidence supports that healed rotator cuff repairs show improved patient reported and functional outcomes compared to physical therapy and unhealed rotator cuff repairs
Moderate strength evidence does not support the routine use of acromioplasty as a concomitant treatment as compared to arthroscopic repair alone for patients with small to medium sized full-thickness rotator cuff tears
Moderate strength evidence supports the use of distal clavicle resection as a concomitant treatment to arthroscopic repair for patients with full-thickness rotator cuff tears and symptomatic acromioclavicular joints [1]

Summary

This study found that physical therapy was equivalent to acromioplasty and supraspinatus repair + acromioplasty in older patients with nontraumatic supraspinatus tears
Elective surgical studies often have high crossover rates which can bias the study findings. This study had a low crossover rate (six patients) which further validates its findings.
Older patients with nontraumatic supraspinatus tears should give physical therapy a considerable try before electing to have surgery

SHOULDER | Impingement syndrome

Overview

Impingement syndrome (also referred to as subacromial impingement and subacromial pain syndrome) is marked by shoulder pain that occurs on top of the shoulder joint beneath the acromion. The pain typically occurs when the arm is raised above shoulder level. See illustration of subacromial space.
Impingement syndrome accounts for up to 70% of all shoulder pain syndromes and is a leading indication for shoulder surgery
The proposed mechanism for impingement syndrome is mechanical contact between the supraspinatus tendon and the acromion that occurs when the acromion forms bone spurs and other arthritic changes
Patients with impingement syndrome and shoulder pain often have MRIs done. The MRI may show degenerative changes, partial thickness rotator cuff tears, and/or abnormalities in the subacromial bursa. These findings are also common in patients without shoulder pain.
The condition is often treated with physical therapy and/or steroid injections. If these modalities fail, arthroscopic subacromial decompression surgery where bone spurs and involved soft tissue are surgically removed may be performed. [2]

Surgery vs Sham Surgery vs No Treatment for Shoulder Impingement Syndrome, Lancet (2017) [PubMed abstract]

A study published in the Lancet enrolled 313 patients with impingement syndrome

Main inclusion criteria

Subacromial pain for ≥ 3 months with intact rotator cuff tendons
Completed exercise therapy and ≥ 1 steroid injection

Main exclusion criteria

Full-thickness torn rotator cuff (partial-thickness tear was allowed)

Baseline characteristics:

Average age 53 years
Average number of shoulder injections received - 2
Average Oxford Shoulder Score - 26

Patients were randomized to one of three groups:

Group 1 (106 patients): Arthroscopic subacromial decompression surgery
Group 2 (103 patients): Sham surgery
Group 3 (104 patients): No treatment
The sham surgery group had arthroscopy performed but no removal of bone or soft tissue was performed
Study was performed at 32 hospital sites with 51 participating surgeons
Patients in the Groups 1 and 2 received postoperative physical therapy but Group 3 did not

Primary outcome: Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat

Results

Outcome	Surgery	Sham	No treatment	Comparisons
Duration: 12 months
Baseline Oxford Score	25	27	26	N/A
Primary outcome (6 months)	32.7	34.2	29.4	1 vs 2 p=0.31 \| 1 vs 3 p=0.019 \| 2 vs 3 p=0.0014
Primary outcome (12 months)	38.2	38.4	34.3	1 vs 2 p=0.85 \| 1 vs 3 p=0.020 \| 2 vs 3 p=0.019
In the Surgery group, 21% of patients had not received surgery at 6 months. At 12 months, 16% had not received surgery. In the Sham surgery group, 11% of patients had received some type of shoulder surgery (non-sham) and 31% had not received any surgery (sham or real) at 6 months. At 12 months, 11% of patients had received some type of shoulder surgery (non-sham) and 22% had not received any surgery (sham or real). In the No treatment group, 11% of patients had received some type of shoulder surgery at 6 months. At 12 months, 24% of patients had received some type of shoulder surgery. In a per-protocol analysis, there was no significant difference between the Surgery group and Sham surgery group at 6 months (p=0.69) and 12 months (p=0.35)

Findings: Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process.

Professional recommendations

In 2019, the British Medical Journal made a strong recommendation against surgery for impingement syndrome
The recommendation said nonoperative management including physical therapy, NSAIDs, exercise, and steroid injections should be used instead - BMJ recommendation

Summary

This study showed that subacromial decompression surgery was no better than sham surgery for impingement syndrome. Both surgery groups were better than no treatment, but this is likely due to the placebo effect of surgery and/or the extra physical therapy that the surgical groups received.
Over the course of the study, a significant number of patients did not receive their assigned treatment, but this was mostly due to subjects not having surgery which indicates that pain and function improved without intervention in a number of people. Only 11% of subjects in Group 2 were true crossovers (received non-sham surgery) at 6 and 12 months. A per-protocol analysis also found no significant effect of surgery.

SHOULDER | Frozen shoulder (adhesive capsulitis)

Overview

Frozen shoulder, also known as adhesive capsulitis, is a condition where the capsule that encases the shoulder joint becomes inflamed, scarred, and contracted (frozen shoulder illustration). Frozen shoulder is estimated to affect between 2 - 5% of the general population. The condition typically has an insidious onset and is most often seen in people ≥ 40 years old. Symptoms of frozen shoulder include deep-seated shoulder and upper arm pain, stiffness, and loss of range of motion. Pain often occurs at night, and daily activities are limited. The cause of frozen shoulder is not completely understood, but risk factors include reduced mobility of the arm (e.g. after surgery, other arm injury), female sex, diabetes, and advancing age. Frozen shoulder can resolve spontaneously, but up to 40% of patients report symptoms 4 years after onset.

STUDY
Manipulation Under Anesthesia vs Surgery vs Physical Therapy for Frozen Shoulder, Lancet (2020) [PubMed abstract]

Design: Randomized controlled trial (N=503 | length = 12 months) in adults with unilateral frozen shoulder characterized by the restriction of passive external rotation in the affected shoulder to less than 50% of the opposite shoulder
Treatment: Manipulation under anesthesia vs Arthroscopic capsular release (surgery group) vs Physical therapy. In the manipulation under anaesthesia group, the surgeon manipulated the affected shoulder in a controlled way to stretch and tear the tight capsule while the participant was under general anesthesia. Steroid injections were given in the manipulation and PT groups and were optional in the surgery group. The surgery and manipulation groups also received PT after their interventions.
Primary outcome: Oxford Shoulder Score (OSS), a 12-item patient-reported outcome measure of shoulder pain and function with five response categories and an overall scale ranging from 0 (worst) to 48 (best), at 12 months. A clinically meaningful target difference was predetermined to be 5 OSS points between physiotherapy and either form of surgery, and 4 points between manipulation and capsular release.
Results:

Primary outcome (OSS score): Manipulation - 38.3, Surgery - 40.3, Physical therapy - 37.2
Average baseline OSS score was 20

Findings: All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthroscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective.

Summary

This study found no meaningful benefit of manipulation under anesthesia or arthroscopic capsular release when compared to physical therapy for the treatment of frozen shoulder. Given the unblinded nature of the interventions, the surgery and manipulation groups were at an inherent advantage. Despite this, no relevant effect was found from these procedures. Patients with frozen shoulder should focus on physical therapy to treat their condition.

ELBOW | Tennis elbow

Tennis elbow

Tennis elbow, also called "lateral epicondylitis," is a common condition that affects many people
Its name comes from the fact that people who play racquet sports (like tennis) are prone to develop it from excessive backhands. Any excessive extending or twisting of the wrist (like turning a screwdriver) can cause tennis elbow.
The most common symptom of tennis elbow is tenderness over the lateral (outside) part of the elbow that is worsened by wrist extension
Doctors often give steroid injections into the tender part of the elbow to help relieve the symptoms. Physical therapy may also be prescribed.

Steroid Injection vs PT vs Steroid Injection + PT vs Placebo for Tennis Elbow, JAMA (2013) [PubMed abstract]

A study in the JAMA enrolled 165 patients with tennis elbow

Main inclusion criteria

Tennis elbow for > 6 weeks
Pain provoked by wrist extension

Main exclusion criteria

Recent injection within 6 months
Recent PT within 3 months
Concomitant neck or arm pain

Baseline characteristics

Average age 49 years
Median duration of symptoms - 16 weeks
Male sex - 62%

Randomized treatment groups

Group 1 (43 patients): Steroid injection
Group 2 (40 patients): Steroid injection + PT
Group 3 (41 patients): Placebo injection
Group 4 (41 patients): Placebo injection + PT
Steroid injection consisted of 1 ml of 10 mg/ml triamcinolone + 1 ml of 1% lidocaine
PT consisted of eight 30 minute sessions of treatment during an 8-week period

Primary outcomes: 1-year global rating of change scores of complete recovery or much improvement, and 1-year recurrence (defined as global rating of change scores of complete recovery or much improvement at 4 or 8 weeks, but not at 8, 12, 26, or 52 weeks)

Results

Outcome	Steroid	Steroid + PT	Placebo	Placebo + PT
Duration: 52 weeks
Complete recovery or much improvement	84%	82%	93%	100%
Steroid injections were significantly worse than placebo injections (RR for better outcome, steroid vs placebo - 0.86, 99%CI [0.75 - 0.99]) PT had no significant effect (RR for better outcome, PT vs none - 1.04 99%CI [0.90 - 1.19], p=0.56) There was no significant interaction between PT and steroid injection
One-year recurrence	55%	54%	20%	5%
Steroid injections caused significantly more recurrence than placebo (RR of recurrence, placebo vs steroid - 0.23 99%CI [0.10 - 0.51]) PT had no significant effect on recurrence (RR for less recurrence, PT vs none - 1.31 [99%CI, 0.73 - 2.35], p=0.25)
At 4 weeks, both steroid injections and PT were significantly better than placebo and no PT, respectively, for recovery or much improvement At 26 weeks, steroid injections were worse than placebo for recovery or much improvement, and PT had no significant effect In the steroid group, 4 patients had skin depigmentation and 3 had subcutaneous fat atrophy

Findings: Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences

Summary

In this well-done study, steroid injections led to acute, short-term improvement at 4 weeks, but worse long-term outcomes (26 and 52 weeks)
Physical therapy did not have a significant effect on long-term outcomes. The effect of physical therapy on short-term outcomes (4 weeks) is unclear since the control group had no intervention, and the difference seen may be attributable to the placebo effect.
The best treatment for tennis elbow appears to be time. In this study, 83% of patients treated with placebo had much improvement or recovery at 26 weeks, and 93% were much improved or recovered by 52 weeks.

HIP | Osteoarthritis

Overview

Degenerative changes of the hip joint can lead to severe pain and disability. Most patients are treated with conservative measures first, and when those are no longer effective, hip replacement surgery is considered.
A popular conservative treatment is steroid injections. The study below compared the effects of steroid injections to placebo injections and education.

STUDY
Steroid/Lidocaine Injection vs Lidocaine Injection vs Education for Hip OA, BMJ (2022) [PubMed abstract]

Design: Randomized, controlled trial (N=199 | length = 6 months) in adults with hip OA and moderate to severe pain for at least 6 weeks
Treatment: Triamcinolone 40 mg/Lidocaine 1% (4 ml) hip injection vs Lidocaine 1% (5 ml) hip injection vs Education only. Hip injections were ultrasound-guided. All 3 groups received education that included exercises and other guidance on pain control. The hip injection groups were single-blinded.
Primary outcome: The primary outcome was current hip pain intensity (hip pain today) reported by the patient, measured using a 0-10 Numerical Rating Scale over six months follow-up (through repeated measures at two weeks, and at two, four, and six months after randomization).
Results:

Baseline pain score: Triamcinolone/Lidocaine - 5.8, Lidocaine - 5.7, Education - 5.7
Primary outcome (mean score over 6 months): Triamcinolone/Lidocaine - 4.2, Lidocaine - 4.7, Education - 5.6
For average pain scores over the course of the study, Triamcinolone/Lidocaine was significantly better than Education (p<0.001) but not Lidocaine (p=0.15).
Pain scores for Triamcinolone/Lidocaine were significantly better than Education at 2 weeks and 2 months but not at 4 months or 6 months
Pain scores for Triamcinolone/Lidocaine were significantly better than Lidocaine at 2 weeks only

Findings: Ultrasound-guided intra-articular hip injection of triamcinolone is a treatment option to add to education for people with hip osteoarthritis.

Summary

This study found no benefit of steroid injections compared to lidocaine injections. The comparison between steroid and education is not meaningful since patients in the education group were unblinded. Furthermore, 94% of patients at baseline stated a preference for injection, which means the education group had a negative bias toward their assigned therapy.
The steroid group had better pain control than the lidocaine group at 2 weeks, which may be secondary to systemic absorption of the steroid, a phenomenon that has been observed in other joint injection studies. From 2 months on, there was no significant difference.
The writeup for this study is odd given that the authors seem to completely ignore the only meaningful finding, which is that steroid injections are no better than lidocaine injections for hip pain

HIP | Trochanteric bursitis

Overview

Trochanteric bursitis of the hip (also referred to as gluteal tendinopathy or greater trochanteric pain) is a common condition that has a prevalence of 10 - 25% and affects up to 25% of women over the age of 50
Symptoms of trochanteric bursitis include pain and tenderness over the greater trochanter of the femur. The greater trochanter is the bony prominence that can be felt on the side of the hip. (see greater trochanter illustration)
The greater trochanter has a bursa (fluid-filled sac) overlying its outer border that provides cushioning and reduces friction between it and the overlying tendon of the gluteal muscle. If the sac becomes inflamed (bursitis), pain can develop.
A popular treatment for trochanteric bursitis is steroid injections into the bursa
The study below compared steroid injections to physical therapy or observation in patients diagnosed with trochanteric bursitis

Steroid injection vs Physical Therapy vs Observation for Trochanteric Bursitis, BMJ (2018) [PubMed abstract]

The trial enrolled 204 patients with trochanteric bursitis

Main inclusion criteria

Age 35 - 70 years
Lateral hip pain for > 3 months
Gluteal tendinopathy confirmed by MRI

Main exclusion criteria

Low back pain and/or sciatica
Steroid injection within 12 months
Hip replacement

Baseline characteristics

Average age - 55 years
Female sex - 82%
Average BMI - 27
Average symptom duration - 24 months

Randomized treatment groups

Group 1 (69 patients) - Physical therapy
Group 2 (66 patients) - Ultrasound-guided steroid injection into affected trochanter bursa
Group 3 (69 patients) - Observation
Betamethasone 5.7 mg or triamcinolone 40 mg were used for the steroid injection along with bupivacaine
Exercise group had 14 individual sessions over eight weeks
The observation group received general information about the condition
Treatment was open-label

Primary outcome: Patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at eight weeks, with longer term follow-up at 52 weeks

Results

Outcome	PT	Steroid	Obs	Comparisons
Duration: 52 weeks
Primary outcome (success at 8 weeks)	77%	58%	29%	1 vs 2, p=0.01 \| 1 vs 3 p<0.001 \| 2 vs 3 p<0.001
Primary outcome (pain at 8 weeks)	1.5	2.7	3.8	1 vs 2, p=0.003 \| 1 vs 3 p<0.001 \| 2 vs 3 p<0.001
Primary outcome (success at 52 weeks)	78%	57%	52%	1 vs 2, p=0.01 \| 1 vs 3 p<0.001 \| 2 vs 3 p=0.46
Primary outcome (pain at 52 weeks)	2.1	2.3	3.2	1 vs 2, p=0.53 \| 1 vs 3 p=0.006 \| 2 vs 3 p=0.034

Findings: For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support education plus exercise as an effective management approach for gluteal tendinopathy.

Summary

Steroid injections for trochanteric bursitis are a popular procedure in the U.S.
This study found that education + exercise was clearly superior to steroid injections and observation in the both the short and long term
The authors included a detailed description of their exercise regimen in the trial supplement. A link to the supplement is available here - exercises for trochanteric bursitis (starts on page 8)

HIP | Hip replacement studies

Overview

Hip replacement surgery is a common treatment for severe hip OA, and it is also performed after a hip fracture
There are two types of hip replacement surgery. In a total hip replacement (THR), the femoral head and the acetabulum (hip socket in the pelvis) are both replaced with a prosthesis. In a partial hip replacement (PHR), also called a hemiarthroplasty, only the femoral head is replaced. See illustration of THR and PHR for more.
The first study below compared THR to PHR in patients with displaced femoral neck fractures. The second study looked at the durability of hip replacements, and the third study compared outcomes between cemented and uncemented hemiarthroplasty.

STUDY
Total vs Partial Hip Replacement for Femoral Neck Fractures, NEJM (2019) [PubMed abstract]

Design: Randomized controlled trial (N=1495 | length = 24 months) in patients with a low-energy displaced fracture of the femoral neck who were ambulatory before their fracture
Treatment: Total hip replacement (THR) vs Partial hip replacement (PHR)
Primary outcome: Any unplanned secondary hip procedure within 24 months after the initial surgery
Results:

Primary outcome: THR - 7.9%, PHR - 8.3% (p=0.79)
Overall mortality: THR - 14.3%, PHR - 13.1% (p=0.48)
Any serious adverse event: THR - 41.8%, PHR - 36.7% (p=0.13)
Received other treatment (crossovers): THR - 7.5%, PHR - 2.9% (p<0.001)

Findings: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months.

STUDY
Durability of Hip Replacement, Lancet (2017) [PubMed abstract]

A study published in the Lancet in 2017 looked at the risk of revision surgery among 63,158 patients who had undergone a total hip replacement
Average age of the cohort at time of surgery was 69 years

^✝Data from **PMID 30782340**
Total hip replacement durability
Years since replacement	Original implant still in place
5	98%
10	95%
15	89%
20	81%
25	58 - 78%^✝
Initial age of surgery	Lifetime risk of revision
50 - 54	Men - 30% Women - 17%
60	15%
> 70 years	8%
Other Average age of cohort at replacement was 69 years Women had an overall lower risk of revision surgery

STUDY
Cemented vs Uncemented Hemiarthroplasty for Intracapsular Hip Fracture, NEJM (2022) [PubMed abstract]

Design: Randomized controlled trial (N=1225 | length = 4 months) in patients 60 years and older with an intracapsular hip fracture
Treatment: Cemented hemiarthroplasty vs Modern hydroxyapatite-coated uncemented hemiarthroplasty
Primary outcome: Health-related quality of life measured with the use of utility scores on the EuroQol Group 5-Dimension (EQ-5D) questionnaire at 4 months after randomization (range of scores, −0.594 to 1, with higher scores indicating better quality of life; range for minimal clinically important difference, 0.050 to 0.075)
Results:

Primary outcome: Cemented - 0.371, Uncemented - 0.315 (p=0.02)
Periprosthetic fractures : Cemented - 0.5%, Uncemented - 2.1% (OR 4.37, 95%CI[1.19 - 24])

Findings: Among patients 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty.

FRACTURES - PROXIMAL HUMERUS FRACTURES

Overview

Proximal humerus fractures account for 5 - 6% of all adult fractures. They are more common in older patients (≥ 65) and in patients with osteoporosis.
Proximal humerus fractures typically occur from a fall on an outstretched hand
About half of proximal humerus fractures are displaced, and most involve the surgical neck (see humerus illustration)
Treatment of proximal humerus fractures is controversial. Orthopedic surgeons often perform internal fixation of the fracture with plate and screws, or they may perform a humeral head replacement which involves removing the humeral head and replacing it with a metal prosthesis. Whether these procedures are superior to nonsurgical treatment is unclear.

Surgical vs Nonsurgical Treatment of Displaced Proximal Humerus Fracture, JAMA (2015) [PubMed abstract]

A study in the JAMA enrolled 250 patients with a displaced proximal humerus fracture

Main inclusion criteria

Age ≥ 16 years
Fracture occurred within 3 weeks
Displaced humerus fracture involving the surgical neck
Enough displacement to consider surgery

Main exclusion criteria

Associated dislocation of the injured shoulder joint
Open fracture
Clear indication for surgery such as severe soft-tissue compromise

Baseline characteristics

Average age 66 years
Average time since injury - 5.7 days
Fracture characteristics: One-part fractures 7% | Two-part fractures - 50% | Three-part fractures - 36% | Four-part fractures 4.5%

Randomized treatment groups

Group 1 (125 patients): Either internal fracture fixation (eg. with plate and screws) that preserved the humeral head or humeral head replacement (hemiarthroplasty)
Group 2 (125 patients): Sling for injured arm for as long as needed (3 weeks was suggested) followed by active rehabilitation

Primary outcome: The Oxford Shoulder Score (range, 0-48; higher scores indicate better outcomes) assessed and averaged over a 2-year period, with assessment and data collection at 6, 12, and 24 months

Results

Outcome	Surgery	Sling + PT	Comparisons
Duration: 2 years
Primary outcome	39	38	diff 0.75, 95%CI [−1.33 to 2.84 points], p=0.48)
In the surgical group, 16 (13%) patients were treated nonsurgically. In the nonsurgical group, 2 (2%) patients received surgery. In the surgery group, 90 patients received locking plates and screws, 10 received hemiarthroplasty, and 9 received other surgeries There was no significant difference at any individual time point between the two groups 11 patients in both groups received secondary shoulder surgery during follow-up

Findings Among patients with displaced proximal humeral fractures involving the surgical neck, there was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence. These results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus.

Summary

The PROFHER study found no benefit of surgical intervention for displaced proximal humerus fractures involving the surgical neck
In general, these fractures should be managed nonsurgically

BIBLIOGRAPHY

1 - AAOS ortho guidelines
2 - PMID 30728120 Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline, BMJ (2019)

ORTHOPEDIC STUDIES