The True “Bottom Line” for Advanced Technology: Patient Outcomes

distal radial malunion for OBuzzOrthopaedic surgery has been blessed with an explosion of diagnostic and therapeutic technology over the last several decades. Improvements in advanced imaging, minimally invasive surgical techniques, and biomaterials and implant design have resulted in both perceived and objectively measurable patient benefits. In many cases, these benefits have been documented with patient-reported functional outcome data as well as improved clinical outcomes such as range of motion, strength, return to work, and pain relief.

However, some of these technological advances serve as expensive substitutes for many of the basic procedures that are universally available at a fraction of the cost, such as taking a thorough history, performing a complete physical examination, and employing basic and time-tested surgical techniques when indicated. While new minimally invasive techniques and computer-assisted preoperative planning are impressive in many respects, it is important to remember the ultimate goal of any orthopaedic operation: improving the patient’s musculoskeletal function.

In the July 18. 2018 issue of The Journal, Buijze et al. examine results from a multicenter randomized trial that compared patient-reported outcomes after using either 2-dimensional (standard radiographs) or 3-dimensional (CT with computer assistance) planning for corrective osteotomy in patients with a distal radial malunion. Although post-hoc analysis revealed that this study was underpowered, the patient-reported outcomes (as measured by DASH and PRWE) were not significantly different between the two preoperative planning groups.

These findings do not mean that advanced technology does not have a place in preoperative planning, but for me the findings emphasize that the most important factors in any orthopaedic surgery are the surgeon’s judgment, skill, and experience. When a surgeon needs assistance maximizing one of those three variables, more advanced technologies may play a role in improving patient outcome. For example, among less experienced surgeons, I suspect that more detailed preoperative planning for a relatively uncommon procedure would improve patient outcome, but it would probably have little impact on the results of procedures performed by more experienced surgeons.

The authors of this study focus on the true bottom line for any surgical intervention: patient outcome. But the other bottom line must also be considered. With the per-procedure incremental cost of 3-D planning and patient-specific surgical guides for upper-extremity deformity corrections estimated to range between $2,000 and $4,000, we must continue to conduct this type of Level I research. For the days of laying one “advance” on top of another with no attention paid to the cost for individual patients and the overall system are long gone.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Spine Surgery 2018, Part II

Spine_Graphic for OBuzz

Previously, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 25 studies cited in the June 20, 2018 Specialty Update on Spine Surgery.  In this OrthoBuzz post, Theodore J. Choma, MD, author of the Specialty Update on Spine Surgery, selected his “top five.”

Spondylolisthesis
–A registry study of 765 patients with adult isthmic spondylolisthesis and at least 2 years of post-treatment outcome data found that at 1 year, global-assessment improvements were reported in 54% of patients who underwent uninstrumented posterolateral fusion, 68% of patients who underwent instrumented posterolateral fusion, and 70% of patients who underwent interbody fusion. Although similar patterns were seen in VAS back pain scores and in 2-year data, fusion with instrumentation was associated with a higher risk of reoperation.

Acute Low Back Pain
–In a cost analysis using data from a previously published Level-II study that randomized 220 patients with acute low back pain to early physical therapy or usual (delayed-referral) care, authors concluded that the incremental cost of early PT was $32,058 per quality-adjusted life year and that early PT is therefore cost-effective.1

Metabolic Bone Disease
–A randomized trial of 66 women ≥50 years of age who had osteoporosis and had undergone lumbar interbody arthrodesis found that those who received once-weekly teriparatide for 6 months following surgery demonstrated higher fusion rates than those in the control cohort (69% versus 35%). Once weekly teriparatide may be worth considering to improve fusion rates in this challenging patient population.

Adult Deformity Correction
–To test the hypothesis that performing 3-column osteotomies more caudally in the lumbar spine might improve sagittal malalignment correction, authors analyzed 468 patients from a spine deformity database who underwent 3-column osteotomies.2 The mean resection angle was 25.1° and did not vary by osteotomy level. No variations were found in the amount of sagittal vertical axis or pelvic tilt correction, but lower-level osteotomies were associated with more frequent pseudarthroses and postoperative motor deficits.

Spinal Cord Injury
–Authors directly measured the mean arterial pressure and cerebrospinal fluid pressure in 92 consecutive patients with traumatic spinal cord injury. Using that data to indirectly monitor the patients’ spinal cord perfusion pressure,3 the authors found that patients who experienced more episodes of spinal cord perfusion pressures <50 mm Hg were less likely to manifest objective improvements in spinal cord function.

References

  1. Fritz JM, Kim M, Magel JS, Asche CV. Cost-effectiveness of primary care management with or without early physical therapy for acute low back pain: economic evaluation of a randomized clinical trial. Spine (Phila Pa 1976).2017 Mar;42(5):285-90.
  2. Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O,Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter?J Neurosurg Spine. 2017 Nov;27(5):560-9. Epub 2017 Sep 8.
  3. Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J,Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. 2017 Oct 17;89(16):1660-7. Epub 2017 Sep 15.

Immobilization after Fixation of Distal Radial Fractures

short arm castOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in JBJS.

Postoperative immobilization after internal fixation of fractures is common practice. However, immobilization after locked volar plate fixation of distal radial fractures may actually thwart our patients’ rehabilitation—at least in the short term. So suggest the findings from Watson et al. in the July 5, 2018 issue of JBJS.

The authors randomized 133 patients who underwent locked volar plate fixation of distal radial fractures to 1, 3, or 6 weeks of postoperative immobilization. All patients were placed into volar splints postoperatively. After 1 week, splints were removed entirely or converted to short-arm circumferential casts based on the patient’s allocation. All patients started physical therapy within 3 days of definitive splint or cast removal.

Outcomes were evaluated at 6, 12, and 26 weeks and included patient-reported measures (PRWE, VAS pain scores, and DASH), active wrist range of motion, and postoperative complications. Six weeks following surgery, the results favored 1 or 3 weeks of immobilization over 6 weeks of casting in terms of improved patient-reported outcomes and objective wrist range of motion. However, those between-group differences disappeared at 12 and 26 weeks of follow-up. No significant differences were found in complication rates between the 3 groups.

For me, the primary message of this article is that early mobilization after distal radial fracture fixation offers improved short-term outcomes with little or no risk of adverse effects. For most patients, a major goal of fracture treatment is to restore normal function as quickly as possible. With early mobilization, patients reported less pain and less disability, and they demonstrated greater range of motion at 6 weeks.

However, the quick restoration of function must be done safely and without complications. In this cohort, 6 patients lost fracture reduction—5 in the 1-week immobilization group and 1 in the 6-week group. While that difference was not statistically significant, the study was not sufficiently powered to detect that difference. A quick power analysis, assuming an anticipated 11% loss-of-reduction rate as seen in the 1-week group and a 2% rate as seen in the 6-week group, estimates that 234 patients would be needed to confidently avoid a type II error when analyzing loss of reduction.

Translating findings like these into practice constitutes the art of medicine. It is probably safe, and perhaps even beneficial, to allow early mobilization of distal radial fractures treated with volar locking plates. However, there is probably a subset of patients who are at risk for losing reduction, and therefore it may be prudent to have a low threshold for keeping certain patients casted for a longer duration. The orthopaedist who extends cast immobilization beyond 3 weeks can take comfort in the findings that reported outcomes and range of motion in the 6-week-immobilization group quickly caught up with the results of the early-mobilization cohorts by 12 weeks after surgery.

Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.

Fluctuating Glucose Levels Linked to Post-TJA Problems

Blood Sugar Test for OBuzzAt any given time, a patient’s blood-glucose level is easy to measure. Beyond the standard pre/postoperative lab values, there are finger sticks, transdermal meters, and other modalities that make taking a patient’s glucose “snapshot” pretty straightforward.  So why don’t we surgeons keep track of it more frequently before and after joint replacement, when, according to the prognostic study by Shohat et al. in the July 5, 2018 issue of JBJS, fluctuating glucose levels can have a critical impact on outcomes?

By retrospectively studying more than 5,000 patients who had undergone either total hip or total knee arthroplasty, the authors found that increased variability of glucose levels (measured by a coefficient of variation) was associated with increased risks of 90-day mortality, surgical-site infection, and periprosthetic joint infection. Specifically, the authors demonstrated that for every 10-percentage-point increase in the glycemic coefficient of variation, the risk of 90-day mortality increased by 26%, and the risk of periprosthetic or surgical-site infection increased by 20%. These are remarkable increases in extremely important outcome measures, and the associations held regardless of the patient’s mean glucose values prior to or after the surgery.  In fact, some of the highest levels of glucose variability were found in patients who had well-controlled glucose levels preoperatively. Furthermore, as Charles Cornell, MD points out in a commentary on this study, “Glucose variability appears to affect surgical prognosis more than chronic hyperglycemia.”

These findings were surprising and a bit concerning. I don’t tend to order routine blood-glucose measurements postoperatively on patients who appear to be euglycemic based on preoperative testing. Yet, according to these data, maybe I should. Findings of high glucose variability postoperatively might now prompt me to consult with endocrine or perioperative medicine specialists or at least consider informing patients with fluctuating glucose levels that they may be at increased risk of serious postoperative complications.

Measuring a patient’s blood sugar is neither challenging nor prohibitively expensive. So why don’t we monitor it more closely? Probably because, until now, we have not had a compelling reason to do so with “low-risk” patients. What this study suggests is that our definition of a “low-risk” patient from a glycemic-control standpoint may be misinformed.  And while further research needs to be performed to corroborate these findings, that is a pretty scary thought to digest.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Adductor Canal Block Compared with Periarticular Bupivacaine Injection for Total Knee Arthroplasty

In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. #JBJS #JBJSInfoGraphics #visualabsrtact

Full article: https://bit.ly/2zrZvJW

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Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture

Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). #JBJS #VisualAbstract

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Guest Post—Peer Reviewers: Who Are They and Do They Agree?

Medical-Research Image for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher Dy, MD, MPH, in response to a recent study in PNAS.

I am a young surgeon, but I have been submitting papers and grants for peer review for 11 years, since I was a third-year med student. I have tasted the bitterness of rejection more times than I would like to admit, several times at the hands of JBJS. But I will say, without a doubt, that the peer-review process has made my work better.

Acknowledging that our work is far from perfect at the point of submission, most of us have turned the question around: How good and reliable is the peer-review process? Several related questions arise quickly: Who are the “peers” doing the reviewing? We put weeks and months into writing a paper or submitting a grant, which then vanishes into the ether of a review process. How do we know that we are getting a “fair shake” from reviewers, who, being human, carry their own biases and have their own limitations and knowledge gaps—in addition to their expertise? And do the reviewers even agree with each other?

Many authors can answer “no” to that last question, as they have likely encountered harmony from Reviewers 1 & 3 but scathing dissent from Reviewer 2. Agreement among reviews was the question examined by Pier et al. in their recent PNAS study. Replicating what many of us consider the “highest stakes” process in scientific research, NIH peer review, the authors convened four mock study sections, each with 8 to12 expert reviewers. These groups conducted reviews for 25 R01 grant proposals in oncology that had already received National Cancer Institute funding. The R01 is the most coveted of all NIH grants; only a handful of orthopaedic surgeons have active R01 grants.

Pier et al. then evaluated the critiques provided by the reviewers assigned to each proposal, finding no agreement among reviewer assessments of the overall rating, strengths, and weaknesses of each application.  The authors also analyzed how well these mock reviews paired to the original NIH reviews. The mock reviewers (all of whom are R01-funded oncology researchers) “rated unfunded applications just as positively as funded applications.” In their abstract, Pier et al. conclude that “it appeared that the outcome of the [mock] grant review depended more on the reviewer to whom the grant was assigned than the research proposal in the grant.”

From my perspective as a taxpayer, this is head-scratching. But I will leave it to the lay media to explore that point of view, as the New York Times did recently. As a young clinician-scientist, these results are a bit intimidating. But these findings also provide empirical data corroborating what I have heard at every grant-funding workshop I’ve attended—your job as a grant applicant is to communicate clearly and concisely so that intelligent people can understand the impact and validity of your proposed work, regardless of their exact area of expertise. With each rejection I get, either from a journal or a funding agency, I now think about how I could have communicated my message more crisply.

Sure, luck is part of the process. Who you get as a reviewer clearly has some influence on your success. But to paraphrase an axiom I’ve heard many times: The harder I work, the more luck I seem to have.

Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.

JBJS 100: SCFE Outcomes, Scoliosis Treatment

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Long-term Follow-up of Slipped Capital Femoral Epiphysis
B T Carney, S L Weinstein, J Noble: JBJS, 1991 January; 73 (5): 667
In this retrospective study of 155 hips with SCFE followed for a mean of 41 years after onset of symptoms, Carney et al. found that pinning in situ provided the best long-term function and delay of degenerative arthritis—and that realignment techniques were associated with a risk of substantial complications.

Treatment of Scoliosis: Correction and Internal Fixation by Spine Instrumentation
P R Harrington: JBJS, 1962 June; 44 (4): 591
The need for this at-the-time revolutionary instrumented approach was the polio epidemic, which left Dr. Harrington caring for many patients with severe, collapsing curves that threatened their health. Just as current hip arthroplasty techniques represent incremental improvements to the contribution of Charnley, current techniques in scoliosis surgery are stepwise improvements to Harrington’s work.

Racial Disparities in Health Outcomes Tied to Unequal Access to Care

hip 2Most health researchers attribute the well-defined racial disparities seen in outcomes for both acute and chronic illnesses to unequal access to health care, particularly preventive care. There are currently between 30 million and 40 million uninsured patients in the US who do not have access to routine preventive care and receive the majority of their health care through hospital emergency rooms. This seems to be related to  the prevailing opinion in our country that access to primary care physicians and routine preventive measures is not a basic right.

Emergency care, however, is more or less available to everyone, and that would theoretically reduce or eliminate the racial disparities in outcomes for emergent conditions such as hip fractures. Yet, in 2016, JBJS published research indicating that disparities in care and outcome occur in the management of hip fracture, with black patients found to be at greater risk for delayed surgery, reoperation, readmission, and 1-year mortality than white patients. That begs the question whether there are inherent racial differences beyond the health-care delivery system that might partly account for these disparate outcomes.

In the July 5, 2018 issue of The Journal, Okike et al. try to answer that question. The authors used data from Kaiser Permanente, a large health system with a modestly diverse population that has equal access to care that is known for its adherence to standardized protocols. Okike et al. analyzed the outcomes of nearly 18,000 hip fracture patients according to race (black, white, Hispanic, and Asian). In this uniformly insured population with few or no barriers to access, Okike et al. found that the outcomes for patients, regardless of race, were similar.  These findings strongly suggest that when patients are given equal access to health care that is delivered according to standardized protocols, the racial disparities found in previous studies of outcomes of emergent conditions may disappear.

Okike et al. are quick to emphasize that their findings are not an indication that “efforts to combat disparities are no longer required.” I would argue that this study further supports the need to address the issue of access to care on a policy level if we are  going to make progress toward achieving racial equality in medical and orthopaedic outcomes. Much of the access-to-care progress we made between 2008 and 2016 is evaporating; I look forward to the day when we can redirect the national focus on this issue at the highest policy-making levels.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot

Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. https://bit.ly/2IuVOm1

Related video from JBJS Essential Surgical Techniques.

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