The Brigham’s orthopaedic care programs are built on a strong foundation of results from basic research studies and clinical investigations undertaken by physician scientists. Those research endeavors are now gaining international recognition and attention. Earlier this year, two Brigham clinical investigators were honored by the Hip Society. Both are part of teams whose research papers were selected for two of the three annual Hip Society Scientific Awards, which honor outstanding contributions and important advances in the field.
“As the chair of the Department, I am very proud of Drs. Antonia Chen and Richard Iorio for winning two of the most coveted awards in the field of joint arthroplasty,” said James Kang, MD, Thornhill Family Professor of Orthopaedic Surgery and chair of Department of Orthopaedic Surgery. “The Hip Society has historically given awards to some of the most important and groundbreaking research teams in the world. To have two Brigham faculty members independently win these awards is a true achievement. I know that our entire Orthopaedic team will continue to lead cutting-edge research with more accolades to come.”
Investigating Pain Management
Antonia Chen, MD, MBA, is a practicing orthopaedic surgeon and the kind of dedicated researcher who finds all facets of research in her field fascinating. Chen’s initial interest in joint infection has blossomed into research projects that touch on many dimensions of clinical outcomes after total hip and knee replacements. Her studies cover a range of subject areas, including infection and arthrofibrosis (joint stiffness) after total joint replacements, the impact of “pre-habilitation” (activity prior to surgery to improve postoperative outcomes), activity after joint replacement and opioid use following hip and knee replacements.
The Hip Society research award presented to Chen and her colleagues honors her research on opioid usage. Chen is the senior author of a paper titled, “Cluster-Randomized Trial of Opiate-Sparing Analgesia after Discharge from Elective Hip Surgery,” which received the 2019 Otto Aufranc Award.
Chen’s work in this area began while she was at the Rothman Institute. Chen was later drawn to the Brigham by the potential to conduct research that could help advance the Orthopaedics Department and improve outcomes for patients.
“Coming to the Brigham represented a huge opportunity to build something new at a world-class institution,” she says.
Chen’s study explores whether a scheduled, multimodal approach to pain management — using drugs that target distinct, complementary pain pathways — can reduce the number of opioids needed at discharge after total hip replacement to achieve good pain control for patients. While it may sound like a simple question, Chen and her colleagues found it was a particularly challenging one to study.
The study was designed to have three arms: 1) patients were prescribed pain medications on a fixed schedule with a minimal two-day opiate supply (10 tablets each of oxycodone and tramadol), 2) patients were prescribed the same scheduled-dose regimen, but with a conventional two-week supply of opiates (60 tablets each of oxycodone and tramadol) and 3) patients were prescribed acetaminophen as needed in addition to a two-week supply of opiates. Clusters of surgeons involved in the study rotated between using each of these interventions as “standard of care” for patients during a four-week period.
Chen and her colleagues found that the patients who received the least narcotics reported having the least amount of pain, the greatest satisfaction, and the least side effects.
“We were pleasantly surprised to see that,” said Chen. “We think that the multimodal approach on a schedule helps patients stay ahead of the pain. They also report sleeping better and having fewer opioid-related side effects. Perhaps we need to consider that a little pain can be okay after surgery, and using less narcotics can lead to a better recovery pathway. We don’t want our patients to expect to take many narcotics after surgery, and then pay for it with side effects.”
Chen says the aspect of her study she finds most exciting is its potential to change the way opioids are prescribed after major surgical cases, such as total joint replacement.
“Most studies are retrospective, but this was a prospective study with a version of randomization. It’s a potentially practice-changing project,” she said. “This is a relatively simple change that could potentially improve the way we practice medicine.”
Examining Total Hip Replacement Approaches
Surgeons and patients alike have shown enormous interest in approaches to hip replacement that could offer quicker recovery and fewer complications. Anecdotal evidence abounds about what approach works best, but few studies have set out to distinguish myth from fact based on rigorous analysis. Richard Iorio, MD, chief of the Adult Reconstruction and Total Joint Arthroplasty Service in the Department of Orthopaedic Surgery and vice chairman of Clinical Effectiveness, set out to address this knowledge gap.
“Hip replacement is a wonderful operation and recent advancements in pain management and infection prevention have improved all approaches and led to rapid recovery,” said Iorio. “Our study suggests that early enthusiasm for the newer direct anterior approach over non-anterior isn’t necessarily warranted. Although a good surgeon can do a great job with it, there appears to be a learning curve.”
Iorio and his co-authors were selected for the 2019 Frank Stinchfield Award for their paper titled “An Approach Based Comparison of Periprosthetic Joint Infection Rates in Total Hip Arthroplasty: A Single Institution Experience.” In this work, the team compared the overall rates of infection for approximately 2,000 patients who received direct anterior (DA) and approximately 4,000 patients who received non-anterior (NA) total hip arthroplasty (joint replacement). The team found a higher rate of infection for the DA group (1.22 percent) versus the NA group (0.63 percent). Infection prevention protocols lowered rates for both groups. The authors also noted that the infection rate decreased over time, perhaps as surgeons gained experience in using the approach.
Iorio and colleagues conducted the study at New York University, Iorio’s previous institution. They now plan to embark on a multi-center, randomized trial of 1,000 patients to help determine which infection prevention protocols are most important for reducing infection rates. The Brigham will be one of the study sites.
Iorio speaks proudly of his colleagues in the Brigham’s Orthopaedics Department.
“We have some of the most innovative, up-and-coming arthroplasty surgeons in the country,” he said. “The Brigham has a long history of leadership in arthroplasty, and Dr. Kang has re-energized the department. With advancements in basic and clinical research leading to improvements in practice, we’re going to keep that momentum going and bring the best possible care to our patients.”