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.

• 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
• In the two studies above, PT with optional repair was similar to early ACL repair for pain and function outcomes. In both trials, 50% of the PT group eventually had surgery, so no meaningful comparisons between PT and surgery can be drawn. The studies did show that a wait-and-watch approach is safe and allows some patients to avoid surgery. Until a study with a sham procedure in the control group is performed, the benefits of ACL repair, if any, will remain unknown.

• 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.

• 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.

• 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.

• 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.

• 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

• 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

• 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).

• 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

• 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.

• 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]

• 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.

• 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

• 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

• 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.

• 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)