Another Look at Bisphosphonates and Jaw Osteonecrosis

A recent study in the Journal of Clinical Endocrinology & Metabolism found that approximately one out of 200 Taiwanese who used oral alendronate long term for osteoporosis developed osteonecrosis of the jaw (ONJ). In comparison, among a group treated with raloxifene for osteoporosis, only one out of 1,882 developed ONJ. Risk factors for developing ONJ among alendronate users included diabetes, RA, and exposure to the drug for more than three years.

Although this study reinforces an association between oral bisphosphonates and jaw osteonecrosis, it also demonstrates that this adverse effect is uncommon. While the incidence of ONJ in this study was 7 times higher with alendronate than with raloxifene, the incidence rate of ONJ attributed to alendronate use was only 283 per 100,000 persons per year. The increased relative risk with alendronate is worth noting, but the absolute risk remains low, and for people with osteoporosis, the fracture risk-reduction benefits of bisphosphonates continue to outweigh the risk of jaw osteonecrosis.

How to Become iPad-Savvy

According to the JBJS Mobile Technology and Social Medial Usage Study released in March 2014, on average, orthopaedic surgeons spend approximately 42 minutes a day on tablets. But if you feel like a late-comer to the world of iPads and are not sure where to begin, TopOrthoApps can help you distill which apps are right for you to get started. Data show that surgeons now use tablets for checking formulary schedules, communicating with patients, reading journals and seeking orthopaedic information, TopOrthoApps can help you populate your iPad with the most useful apps available.

Andrews App to Prevent Pitching Injuries

ThrowLikeAProApp

Throw Like A Pro App – available in iTunes.

Young baseball players who want to stay out of the operating room should look into purchasing the Throw Like a Pro app ($9.99 for iPhones and iPads). According to leading surgeons in the field of throwing injuries, this app could reduce throwing injuries by 60% if used correctly. The app, released by James Andrews, MD and Kevin Wilk, DPT receives the highest marks from TopOrthoApps, an app review site, for functionality, coolness and overall features. The app breaks down stretches and exercises that players should do during pre-season as well as in-season. Both pre-season and in-season sections include video showing stretching exercises, warm-ups, and workouts for general throwing and pitching. Included is a modifiable tool that adjusts pitch-count recommendations according to the patient’s age and number of rest days.

Social Media Still Slow to Catch On

More evidence supports low usage of social media among physicians. According to the JBJS Mobile Technology and Social Media Usage Study among Orthopaedic Surgeons, few orthopaedic surgeons were interested in LinkedIn or Facebook. With the exception of VuMedi, fewer than 40% said social media has any utility in their practice. This finding was validated by MedData Group’s study in June 2014, which found that 44% of physicians in the US were not using social media for professional purposes. That study also revealed that only 32% of the responding physicians used LinkedIn and only 29% use online physician communities

Residents Predict Medical Apps Will Play Major Role

According to the JBJS 2014 Readership Study, residents are frequent users of mobile medical apps, with 76% saying they have a medical app on their smartphone. Over the next 2 years, residents anticipate that their app usage will become an even greater part of their daily use. According to the study, just over half of residents, 52%, say they expect to rely heavily on mobile apps for obtaining clinical orthopaedic information. Residents place mobile apps 4th out of 8 sources in future reliance, with online journals in first place. Orthopaedic surgeons, on the other hand, rate mobile apps lower in future importance, with roughly a third, 36%, saying they’ll rely on mobile apps the most. For surgeons, online and print journals are at the top of the list.

 

Residents

Surgeons

The True Value of Hip-Fracture Surgery

Currently, each year more than 300,000 Americans sustain a hip fracture, and that number is expected to rise to more than 500,000 within the next 20 to 30 years. A new study– based on a literature review, analysis of Medicare claims, and input from clinical experts–finds that the average lifetime societal from surgery to repair hip fractures reduced the direct medical costs of the surgery by $65,000 per patient. Collectively, that results in an estimated$16 billion lifetime societal savings. These savings include reductions in length of and intensity of postinjury care, and the amount of required long-term medical care and assistance required by surgery patients relative to those whose fractures are treated nonsurgically. The study, published in Clinical Orthopaedics and Related Research, also found that the quality-adjusted life years in people with surgically treated hip fractures increased 2.5 years for patients with intracapsular fractures and 1.9 years for those with extracapsular fractures. To view a summary of the article, read here.

Editor’s Choice—JBJS Reviews, September 2014

It would be an understatement to suggest that the practice of medicine has changed during the past ten years. Indeed, every physician can think of a number of things that have impacted his or her practice. However, among the positive changes that have affected how we treat patients, evidence-based medicine ranks high on the list.

Evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patient values.” Those who support evidence-based medicine note that it will prevent the bias that exists among health-care professionals who frequently base clinical decisions on custom and practice. Hence, the growth of evidence-based medicine along with the desire among clinicians to reduce variations in health-care delivery has had an important and positive impact on health-care practice and policy. Simply stated, the principles of evidence-based medicine serve as a means of decreasing variation in health-care delivery and improving patient outcomes.

The history of evidence-based medicine is interesting and is well covered in the article by David Jevsevar in the September 2014 issue of JBJS Reviews. Concepts and terms are defined, and the findings of research on health-care disparity are discussed. Clearly, the randomized controlled trial (RCT) has become the so-called gold standard in research methodology because of its ability to minimize confounding between patient groups. However, Dr. Jevsevar notes that there are concerns regarding the use of RCTs in the practice of medicine, including their expense as well as the time required for patient recruitment, data analysis, and study completion. As a result of these costs and challenges, most RCTs are now funded by industry, raising concerns about the potential external sources of bias.

This article also touches on other important concepts related to evidence-based medicine in clinical practice policy, such as the propagation and control of conflicts of interest, shared decision-making between physician and patient, and the development of best-practice applications to address the individual needs of and risks to each patient. Finally, it is apparent that the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010 introduces important and vast changes in access to the U.S. health-care system. Designed to address the unsustainable growth in federal spending and the depletion of the Medicare trust fund that is predicted to occur by 2026, this legislation represents an attempt to “bend the cost curve” by showing the increase in annual health-care expenditures. It further makes the point that the absence of an essentially controlled U.S. health-care system creates a potentially large research laboratory promoting study opportunities to investigate the delivery of high-quality, evidence-based care. Thus, the opportunity for orthopaedic surgeons to become advocates for their patients, to take a leading role in shaping the future of evidence-based medicine, and to do so in a way that generates costs that our nation can afford presents a real opportunity to positively shape the future of orthopaedic practice.

Thomas A. Einhorn, MD, Editor, JBJS Reviews

Editor’s Choice—Essential Surgical Techniques – September 2014

O’Driscoll et al. have included 13 videos in their excellent description of a safety-driven technique for arthroscopic arthroplasty of the elbow. While detailing a four-step process for both the anterior and posterior compartments, in eight of the videos, these authors simultaneously display both the exterior surgical field and the intra-articular arthroscopic view with a “picture-in-picture” format. Viewers can thus see what camera and instrument maneuvers the surgeon is performing to achieve the arthroscopic views and surgical goals. Furthermore, the technique videos are “chaptered” so viewers can easily locate, replay, and study specific details at their leisure.

Edward Y. Cheng, MD, Editor, Essential Surgical Techniques

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves.

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves. Source: JBJS Essential Surgical Techniques (3/3/e15)

“New” but Not Necessarily “Improved”

A review of five hip- and knee-implant innovations, initiated by the FDA in reaction to serious problems with metal-on-metal hip bearings, found that none offered meaningful functional or patient-outcome benefits over older designs. The systematic review of 118 studies and more than 13,000 patients, published in the BMJ, also found that three of the new designs—ceramic-on-ceramic hip bearings, modular femoral necks, and high-flexion knee implants—were associated with higher revision rates relative to established designs. The other two innovations—uncemented monoblock acetabular cups and sex-specific knee implants—provided no benefit over older designs but had comparable revision rates.

The BMJ authors claim that the purpose of the review was not to “criticise the surgical community or orthopaedic industry,” but rather to “highlight that the status quo regarding the introduction of new device technologies is not acceptable.”

The BMJ authors cite stepwise introduction of new implant technologies as one way to avoid exposing large numbers of patients to innovations whose safety and efficacy are unproven. In a 2011 JBJS supplement, authors (two of whom also co-authored the BMJ study) proposed using roentgen stereophotogrammetric analysis (RSA) and national joint registry data to facilitate phased clinical introduction of new implants.

From Sutures to Staples to….Zippers?

The Zip Surgical Skin Closure device from ZipLine Medical (Campbell, CA) is an intriguing recent evolution in surgical wound closure. If the experiences of two orthopaedic surgeons from OrthoIndy in Indianapolis are any indication, this innovative method could be poised for clinical take-off.

Jack Farr, MD and David A. Fisher, MD, (both authors of JBJS-published papers) have observed improved patient satisfaction with Zip, as compared with sutures or staples. In an article they contributed to Orthopedics This Week (subscription required), Drs. Farr and Fisher also tout the theoretical reduction in infection risk, seeing as Zip closes wounds without perforating the skin.

The Zip attaches to the skin adjacent to the incision with a hydrocolloid adhesive. The individual straps for wound tensioning carry the potential to distribute closing forces more evenly than sutures or staples, and “in our experience, applying the Zip took about the same amount of time as applying staples,” Farr and Fisher wrote. The incision remains exposed in the center of the device so absorptive dressings placed on top can collect wound exudates.

Another significant advantage is the increased range of motion that Zip allows due to the device’s “programmed separation” feature, which permits it to lengthen upon joint flexion without stressing the incision. Four days after partial knee replacement surgery closed with Zip, Dr. Farr himself was using a stationary bike. Farr and Fisher also report reduced patient apprehension about removal. Zip is simply peeled off, easing the trepidation that’s often associated with staple removal.

Although the OrthoIndy experience with Zip has been uniformly positive, it has been anecdotal. To bolster the evidence base, Drs. Farr and Fisher (neither of whom reportedly has any financial stake in ZipLine Medical) are planning a prospective randomized, controlled study on “bilateral partial or total knee patients to measure the differences between the Zip and staples.”

Follow

Get every new post delivered to your Inbox.

Join 44 other followers