Three New Studies: CT Scans Uncover Widespread SI Joint Degeneration // Distressed Patients Mean Dissatisfaction With Surgeon // and More!

CT Scans Uncover Widespread but Asymptomatic SI Joint Deterioration

Sometimes you must return to the basics in order to go forward. Such was the thinking behind new research on sacroiliac (SI) joint degeneration from Stanford University and Bellevue Bone and Joint Physicians in Washington. Jonathan-James Eno, M.D., an orthopedic resident at Stanford, told OTW, “For our study, which was just published in The Journal of Bone and Joint Surgery, the goal was to establish a baseline prevalence of sacroiliac joint degeneration in the asymptomatic population. We undertook this topic because the prevalence of low back pain continues to be a huge burden on society, and the potential for the SI joint as a source of low back pain has led to a renewed interest in surgical or procedural intervention, including injections and fusions. Arthrodesis has made a comeback recently, in part, because of the introduction of more minimally invasive approaches.”

“Surgeons have traditionally relied heavily on radiographic findings of SI joint degeneration to implicate it as a source of pain. We wanted to evaluate how many asymptomatic patients had radiographic evidence of underlying SI joint pathology. A high prevalence of degenerative changes in the asymptomatic population would suggest that these changes are not necessarily indicative of a source of low back pain in each patient.”

“We reviewed 500 consecutive pelvic computed tomography (CT) scans of patients who had no history of pain in the lower back or pelvic girdle. We excluded individuals who were skeletally immature, had a history of spinal instrumentation, a history of low back, pelvic, or hip pain, a history neurological disease, and those who had undergone prior surgery; we were left with 373 CT scans (746 sacroiliac joints).”

“The average age of patients was 57, and we had roughly 1:1 male to female ratio. Each CT was reviewed by the senior author and an orthopedic trauma fellow, then it was classified using our proposed novel classification system. The classification system ranges from 0 (no degenerative changes) to 3 (complete ankylosis of the SI joint). We found that the overall prevalence of SI joint degeneration in at least one joint was 65%; there was significant SI joint degeneration (type 2/3) in almost 31% of the SI joints in our cohort.”

“The message is simply to be cautious when correlating radiographic findings with clinical symptoms. It may be tempting to attribute lower back or pelvic girdle pain to SI joint degeneration seen on a CT, but further investigation to confirm the source of pain may be warranted. Our study should not necessarily discourage our colleagues from operating on the SI joint; it should, as is the case with all of medicine, reinforce the need to correlate clinical presentation, radiographic findings, and confirmatory studies to ultimately determine the correct diagnosis and guide proper treatment.”

Distressed Patients=Lower Satisfaction Scores

Orthopedic surgeons are not psychologists. And yet, says data from a study recently published in The Journal of Bone and Joint Surgery, you might want to brush up on your listening skills. Amir Abtahi, M.D., chief orthopedic resident at the University of Utah, tells OTW, “At first glance the concept of patient satisfaction doesn’t seem like it would be overly complicated, but there has been some research that has shown that multiple factors are involved. My colleagues and I wanted to dig deeper in order to find out what factors are influencing this increasingly important quality metric. We decided to explore the influence of distress on patient satisfaction, and we used the Distress and Risk Assessment Method (DRAM) questionnaire, a tool which has been validated in spine patients.”

“We looked at outpatient clinical encounters at a single academic spine surgery center between February 2011 and January 2013. We had 103 patients in the study, all of whom completed both a patient satisfaction survey and a Distress and Risk Assessment Method (DRAM) questionnaire.

We know that distressed patients have poorer outcomes from orthopedic surgical interventions. What we were looking to determine was, ‘How does distress affect satisfaction with the patient’s provider?’”

“Of the 103 patients, 56 showed no evidence of distress, 22 were ‘at risk, ’ 13 were ‘distressed depressive’, and 12 were ‘distressed somatic.’ We found that distressed patients, in particular distressed somatic patients reported significantly lower patient satisfaction scores. (The mean overall patient satisfaction scores were 90.2 in the normal group, 94.7 in the at-risk group, 87.5 in the distressed-depressive group, and 75.7 in the distressed-somatic group. The mean score for the patients’ satisfaction with their provider was 94.2 in the normal group, 94.2 in the at-risk group, 90.6 in the distressed-depressive group, and 74.9 in the distressed-somatic group).”

“We know from a number of previous studies that distressed patients have worse orthopedic outcomes compared to non-distressed patients. This study draws attention to the fact that distressed patients may be more likely to perceive other aspects of their care in a more negative light—including their satisfaction with care. Given that doctors are being assessed on the basis of quality, perhaps we should be adjusting for distress and other patient factors when evaluating physician scores. This is already somewhat of an established concept for inpatient satisfaction surveys. Finally, this study highlights the importance of communication between patient and provider. We are beginning to understand the effect that distress has on various aspects on patient care. If a patient seems to be distressed, it is worth spending a little extra time with them—doing your best to communicate clearly and make sure that they feel heard.”

Delaying ACL Reconstruction Can Cause Trouble in the Trochlea, Elsewhere

If you delay a primary anterior cruciate ligament (ACL) reconstruction, will there be more secondary injuries at the time of surgery? And what kind of injuries will those be? Marc Tompkins, M.D., assistant professor of orthopedic surgery at the University of Minnesota, has answered some of those questions for his colleagues. Dr. Tompkins tells OTW, “There has long been a debate about the timing of ACL surgery. In the U.S. we have a high volume of these injuries; while most of our patients undergo surgery in the early post-injury phase, some wait until the symptoms are really bothering them or delay the surgery for other reasons. Having a primary ACL injury doesn’t necessarily mean that you have to do surgery right away or at all. I discuss this with my patients, reviewing what kind of activities they want to do. Many of them decide to get to the OR sooner rather than later, but the decision to proceed is theirs. ”

“My colleagues and I set out to see if patients whose ACL reconstruction was delayed were more likely to have a secondary intra-articular injury when compared with those who underwent reconstruction immediately following the injury. Our team also hoped to determine if patients who were more active (preinjury) or older were more likely to have a secondary injury when compared with those who were less active and younger.”

“Previous studies have found that there is a link between time of surgery and future injury. We attempted to take the previous information a step further and asked, ‘What about specific areas of the knee like the patellofemoral compartment?’ It sees more stress when you don’t have the anterior/post resistance of the ACL. You also lose rotational functioning of the ACL, so there may be an injury related to shearing in the medial or lateral compartments.”

Dr. Tompkins’ work, a retrospective review on 1, 434 patients who underwent primary ACLR at one institution between 2009 and 2013, was published recently in the American Journal of Sports Medicine. “When we looked at our data, we did find an association between time to surgery and increased incidence of injury in the trochlea, lateral femoral condyle, medial tibial plateau, and medial meniscus. Looking at it by preinjury activity level together with time to surgery, the less active patients were most at risk for medial meniscal and trochlear injury, while the more active patients were most at risk for medial tibial plateau injury.”

“When the cartilage and meniscal injury occurred merits further study. We don’t know for sure that the injuries didn’t occur at the time of the ACL tear, but the fact that there is an association with time to surgery suggests that some of the injuries may have occurred after the ACL tear. It is possible that damage to the cartilage or meniscus can occur just with daily activities when the ACL is not functional. Or, there may have been people in each of the time to surgery groups who went back to playing cutting or pivoting sports between ACL injury and ACL surgery.”