ORTHOPEDIC STUDIES









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.
  • The study below compared early ACL repair to a physical therapy and watch approach in young, active adults
Early ACL Reconstruction vs Delayed Optional Reconstruction, 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 early ACL reconstruction (within 10 weeks)
  • Group 2 (59 patients): Rehabilitation plus optional delayed ACL reconstruction
  • 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

Duration: At 2 years, the following was seen
Outcome Group 1 Group 2 1 vs 2
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 Group 1 did not have surgery, and 23 subjects (39%) in Group 2 underwent ACL repair
  • As-treated analysis (average change in KOOS4 score): Group 1 (n=60) - 39, Group 2 with surgery (n=23) - 39.8, Group 2 without surgery (n=36) - 39.2 (p=0.98)
  • As-treated analysis (return to previous activity): Group 1 (n=60) - 44%, Group 2 with surgery (n=23) - 30%, Group 2 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.
StraightHealthcare analysis
  • This study found that when it comes to ACL tears in young active adults, a physical therapy and watch approach appears to be safe and does not lead to any worse subjective (pain and function) or objective (radiographic) outcomes than an immediate surgical repair approach
  • Because of the high crossover rate (51%), it is not possible to conclude from this study if either approach is superior. In the as-treated analysis, outcomes did not differ, but these types of analyses are often biased.
  • The high rate of meniscal repairs in both groups was a weakness of this study, because this intervention has not been proven to be beneficial
Early ACL Reconstruction vs Delayed Optional Reconstruction - 5 year follow-up results, BMJ (2013) [PubMed abstract]

Duration: After 5 years, the following was seen
Outcome Group 1 Group 2 1 vs 2
Primary outcome (KOOS4 score at 5 years) 80 82 p=0.45
Return to preinjury activity level 23% 20% p=0.73
  • In Group 2, seven additional subjects ended up having surgical ACL repair from years 2 - 5 bringing the total number of ACL repairs in Group 2 to 30 patients (51%)
  • As-treated analysis (KOOS4 score at 5 years): Group 1 (n=59) - 80, Group 2 with surgery (n=30) - 81, Group 2 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.
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



Knee meniscus
  • The meniscus is a cartilage pad in the knee that serves as a cushion between the femur bone and the tibia bone
  • When the meniscus is torn either by trauma or wear-and-tear (see meniscus tear illustration), orthopedic surgeons often "scope" the knee and remove pieces of the torn meniscus. The remaining cartilage is then trimmed back to form a stable rim. The procedure is intended to improve symptoms caused by the torn meniscus (ex. pain, popping, catching, etc.).
  • Arthroscopic partial meniscectomy is the most common orthopedic procedure performed in the U.S.
FIDELITY Study - Surgical Repair 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 meniscus repair
  • Group 2 (76 patients): Sham repair (repair was faked, nothing was actually done to meniscus)
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

Duration: 12 months
Outcome Meniscal repair Sham Comparisons
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 (Group 1 - 14 patients, Group 2 - 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 Group 1 required additional knee surgery, and five patients in Group 2 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.
StraightHealthcare analysis
  • The FIDELITY study is interesting for a number of reasons. It's rare to see a surgical study where the control group is given a sham procedure, particularly one that is invasive. Arthroscopy without meniscal repair still carries risks (ex. infection, bleeding), and convincing patients to sign up for the trial (and subsequent risks) when they may receive no actual treatment would likely be difficult.
  • The trial is very relevant because arthroscopic meniscal repair is a very common procedure, particularly in the U.S.
  • Patients with osteoarthritis were excluded which means the procedure was only performed in patients who would be expected to benefit the most from the procedure. Other studies on meniscal tears have included patients with osteoarthritis (see meniscal tear in osteoarthritis).
  • The post hoc analysis is intriguing because mechanical symptoms have often been attributed to mobility of the torn meniscus. Meniscectomy did not appear to improve these symptoms. It's important to note that Post hoc analyses have many limitations including loss of randomization and power.
  • Study weaknesses:
    • Excluded patients with traumatic onset of symptoms (although a subgroup of patients did have a "sudden onset" of symptoms)
    • Trial excluded patients < 35 years, and average age of subjects was 52 years. It is unclear if results would apply to younger, more active patients.
  • Study strengths:
    • Sham surgical procedure
    • Patients with osteoarthritis were excluded
    • Low crossover rate
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 meniscal repair 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 meniscal repair 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.
FIDELITY Two-year Follow-up, BMJ (2018) [PubMed abstract]
  • A follow-up study looked at two-year outcomes from the Fidelity trial. Over two years, only two patients were lost to follow-up.

Duration: 2 year follow-up
Outcome Meniscal repair Sham Comparisons
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.
Surgical Repair 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): Surgical meniscal repair 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

Duration: 12 months
Outcome Meniscal repair Physical therapy Comparisons
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.
StraightHealthcare analysis
  • This study found no difference between surgical repair and physical therapy in patients with OA and acute meniscal tear. The study had a high crossover rate (30%) which biases the study towards the null. The as-treated analysis showed no significant difference between groups at 6 and 12 months, but these analyses are also prone to bias.
  • The main weakness of the study is that it was unblinded. The FIDELITY Study which used a sham surgery comparator found no benefit of meniscal repair in patients without OA. Past studies that have compared arthroscopic surgery to sham surgery or physical therapy have also found no benefit for patients with OA. [PMID 12110735, PMID 18784099]




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 normally 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, the steroids suppress inflammation and improve knee symptoms. While this treatment is widespread, several placebo-controlled studies detailed below have found it to be of no benefit.
Steroid Injections vs Placebo Injections 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

Duration: 14 weeks
Outcome Saline Steroid Comparisons
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 for Knee OA every 3 months for 2 years, 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

Duration: 2 years
Outcome Steroid Saline Comparisons
Change in total 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.
StraightHealthcare analysis
  • In this study, steroid knee injections showed no obvious benefit in knee OA and were potentially harmful in that they appeared to accelerate cartilage loss
  • The authors note that patients were only evaluated every 3 months, so short-term benefits (< 3 months) of steroid injections cannot be ruled out
  • Steroid knee injections have no proven long-term (≥ 3 months) benefit in knee OA and serial injections may be harmful
AAOS recommendation
  • The AAOS states the evidence is inconclusive to recommend for or against steroid injections for knee OA [1]
StraightHealthcare analysis
  • In both the placebo-controlled trials detailed above, steroid injections were found to be of no benefit in knee OA
  • While popular, steroid injections have mostly fallen flat in well-done, randomized controlled trials. Conscientious patients and providers should largely avoid their use.

Hyaluronic acid injections for knee OA
  • Another 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

Duration: 6 months
Outcome Synvisc Steroid Comparisons
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.
StraightHealthcare analysis
  • In this study, 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
AAOS recommendation
  • The AAOS does not recommend the use of hyaluronic acid injections to treat knee OA [1]

Glucosamine and chondroitin
  • The dietary supplements glucosamine and chondroitin are often used by people to treat knee pain
  • Glucosamine is an amino sugar that serves as a precursor for glycosaminoglycans, a major component of cartilage. This property is used to promote its theoretical effect in treating OA.
  • Chondroitin is a glycosaminoglycan, a major component of cartilage. This property is used to promote its theoretical effect in treating OA.
  • Three placebo-controlled trials of glucosamine/chondroitin for knee OA are presented below
Glucosamine and chondroitin studies

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.

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

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.
AAOS recommendation
  • The AAOS does not recommend glucosamine or chondroitin for knee OA [1]



Knee replacements
  • 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), 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).
  • Knee replacements can fail over time and patients often want to know how long they can expect their replacement to last. Several studies have looked at the durability of knee replacements over time. Results from those studies are summarized in the table below.
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

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%



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

Duration: 12 weeks
Outcome Steroid Placebo Comparisons
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 Group 1 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.
StraightHealthcare analysis
  • Based on this well-done study, most patients with plantar fasciitis can expect about 4 weeks of significant relief with a steroid injections. 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.



Overview
  • The Achilles tendon connects the calf muscle to the heel bone (Achilles tendon image). The tendon may become inflamed (tendonitis) from overuse. Achilles tendonitis typically is seen in runners and middle-aged people who play sports.
  • Autologous blood injections involve taking a person's own blood and injecting it around a tendon to treat tendonitis
  • The theory behind the therapy is based on the fact that blood contains a number of cell-signaling chemicals and growth factors. Injecting blood around the inflamed tendon is supposed to stimulate healing.
  • The procedure has received some notoriety because a number of professional athletes have undergone the procedure or procedures similar to it
  • The treatment is not widely accepted by mainstream medicine because there is no good evidence that it is effective
  • A study in the British Medical Journal evaluated the therapy for Achilles tendonitis
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

Duration: 6 months
Outcome Blood Placebo Comparisons
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.
StraightHealthcare analysis
  • In this study, autologous blood injections had no significant effect on Achilles tendonitis
  • In general, all types of tendonitis are difficult to treat. While a number of therapies have been proposed, time appears to be the most effective treatment.



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.
Physical Therapy vs Acromioplasty vs Rotator Cuff Repair + Acromioplasty, 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 (written instructions and 10 monitored sessions)
  • Group 2 (60 patients): Acromioplasty + physical therapy
  • Group 3 (60 patients): Supraspinatus repair + acromioplasty + physical therapy
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

Duration: 2 years
Outcome Group 1 Group 2 Group 3 Comparisons
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 (Group 1 - 89%, Group 2 - 95%, Group 3 - 94%)
  • Five patients crossed over from Group 1 to surgical treatment
  • Average change in supraspinatus tear on MRI from baseline to 2 years was smaller in Group 3 (Group 1: 9.6 mm at baseline to 10.4 mm at 2 years | Group 2: 9.1 mm at baseline to 11.7 mm at 2 years | Group 3: 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.
StraightHealthcare analysis
  • 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
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.



Shoulder impingement syndrome (subacromial pain syndrome)
  • 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

Duration: 12 months
Outcome Surgery Sham surgery No treatment Comparisons
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 Group 1, 21% of patients had not received surgery at 6 months. At 12 months, 16% had not received surgery.
  • In Group 2, 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 Group 3, 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 Group 1 and Group 2 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.
StraightHealthcare analysis
  • 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.
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



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

Duration: 52 weeks
Outcome Steroid Steroid + PT Placebo Placebo + PT
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
StraightHealthcare analysis
  • 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.



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

Duration: 2 years
Outcome Surgery Sling + PT Comparisons
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.
StraightHealthcare analysis
  • 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



Trochanteric bursitis
  • 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 in 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) - Education + exercise
  • 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

Duration: 52 weeks
Outcome Exercise Steroid Observation Comparisons
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 score 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 score 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.
StraightHealthcare analysis
  • 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 replacements
  • Hip replacement surgery is a common treatment for severe hip OA (see hip replacement illustration)
  • HIp replacements can fail over time and patients often want to know how long they can expect their replacement to last. Several studies have looked at the durability of hip replacements over time. Results from those studies are summarized in the table below.
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

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