How Many X-Rays Does It Take to Treat a Distal Radial Fracture?

We orthopaedists obtain radiographs for many reasons—to diagnose an unknown problem, to determine the progress of healing, and occasionally because we follow X-ray “dogma” acquired over time. That last reason prompted van Gerven et al. to undertake a multicenter, prospective, randomized controlled trial, the findings of which appear in the August 7, 2019 issue of The Journal.

The authors set out to evaluate the clinical utility of radiographs taken after a distal radial fracture in >300 patients. Some of those fractures were treated nonoperatively, while others underwent operative fixation. Surgeons of the patients randomized to the “usual-care” pathway were instructed to obtain radiographs at 1, 2, 6, and 12 weeks following the injury/surgery. Surgeons of patients in the “reduced-imaging” arm did not obtain radiographs beyond 2 weeks after the injury/surgery unless there was a specific clinical reason for doing so.

The authors found no significant differences between groups in any of the 6 patient-reported outcomes measured in the study, including the DASH score. Furthermore, the complication rates were almost identical between the usual-care (11.4%) and reduced-imaging (11.3%) groups. Not surprisingly, patients in the reduced-imaging group had fewer radiographs obtained (median 3 vs 4) and were exposed to a lower overall dose of ionizing radiation than those in the usual-care group.

Probably because the study was conducted in the Netherlands, it did not address the widespread practice of “defensive medicine” in the US—the unnecessary overuse of medical tests and procedures to reduce the risk of a malpractice claim. While that may limit the external validity of these findings among orthopaedists in the United States, this relatively simple yet well-designed study should remind us that it is important to have a definite clinical purpose when ordering a test of any type. A picture may be worth a thousand words, but sometimes it takes only 2 pictures to tell the full story of a healing distal radial fracture.

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

The Softer Side of Better Patient Outcomes

It goes almost without saying that a patient’s return to work after an orthopaedic injury or musculoskeletal disorder would correlate with the severity of the condition. But what about the connection between return to work and a more “touchy-feely” parameter, such as the patient-surgeon relationship?

Dubert et al. conducted a longitudinal observational study of 219 patient who were 18 to 65 years of age and had undergone operations for upper-limb injuries or musculoskeletal disorders. In the August 7, 2019 issue of JBJS, they report that a positive relationship between patient and surgeon hastened return to work and reduced total time off from work.

At the time of enrollment (a mean of 149 days after surgery), the authors assessed the patient-surgeon relationship with a validated, 11-item questionnaire called Q-PASREL, and they collected patients’ functional and quality-of-life scores at the same time. The authors then tracked which patients had returned to work 6 months later, and they calculated how many workdays those who did return had missed.

The Q-PASREL questionnaire explores surgeon support provided to the patient, the patience of the surgeon, the surgeon’s appraisal of when the patient can return to work, the cooperation of the surgeon regarding administrative issues, the empathy perceived by the patient, and the surgeon’s use of appropriate vocabulary.

Here is a summary of the findings:

  • At 6 months after enrollment, 74% of patients who had returned to work had given their surgeon a high or medium-high Q-PASREL score. By contrast, 64% of the patients who had not returned to work had given their surgeon a low or medium-low Q-PASREL score.
  • The odds of returning to work were 56% higher among patients who gave surgeons the highest Q-PASREL scores compared with those who gave surgeons the lowest scores.
  • The “body structure” subscore on one of the functional measurements and the Q-PASREL quartile were the only two independent predictors of total time off from work among patients who had returned to work.

After asserting that their study “confirms that surgeons’ relationships with their patients can influence the patients’ satisfaction and outcomes,” Dubert et al. go on to suggest that the findings should prompt surgeons to “work on empathy, time spent with their patients, and communication.” While they rightly claim that such improvements would entail “little financial investment and no side effects,” perhaps the authors, who practice in France, underestimate the effort that goes into changing behavior—and into addressing the time constraints imposed by the US health care system?

Polytrauma Patients Face Cancer Risk from Imaging Radiation

Orthopaedic surgeons work with radiation in some capacity almost every day. We would struggle to provide quality patient care if it were not for the many benefits that radiographic images provide us. But the more we are exposed to something, the less we tend to think about it. For example, how often do we discuss the risks of radiation exposure with our patients—especially those who are exposed to a large amount of it after an acute traumatic injury?

The article by Howard et al. in the August 7, 2019  issue of JBJS strongly suggests that polytrauma patients need to better understand the risks associated with radiation exposure as they progress through treatment of their injuries. The authors evaluated the cumulative 12-month postinjury radiation exposure received by almost 2,400 trauma patients who had an Injury Severity Score of 16+ upon admission. Those patients received a median radiation dose (not counting fluoroscopy) of 18.46 mSv, and their mean radiation exposure was 30.45 mSv. These median-versus-mean data indicate that a small subset of patients received substantially more radiation than others, and in fact, 4.8% of the cohort was exposed to ≥100 mSv of radiation. To put these amounts in context, the average human in the UK (where this study was performed) is exposed to about 2 mSv of background radiation per year, and there is good evidence suggesting that carcinogenesis risk increases with acute radiation doses exceeding 50 mSv.

Based on mathematical models (actual occurrences of cancer were not tracked), the authors conclude that for these patients, the median risk of fatal carcinogenesis as a result of medical radiation following injury was 3.4%. In other terms, 85 of these patients would be expected to develop cancer as a result of medical imaging—which struck me as a startling estimate.

So what are we to do? In a Commentary accompanying this study, David A. Rubin, MD, FACR offers some practical suggestions for reducing unnecessary radiation exposure. I personally feel that because the radiation associated with CT scans and radiographs can be, quite literally, life-saving for patients who have sustained traumatic injuries, increasing the chance that patients develop cancer later in life in order to save their life now is a good risk-benefit proposition. But the findings from this study should make us think twice about which imaging tests we order, and they should encourage us to help patients better understand the risks involved.

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

Good Outcomes and Savings with Preferred-Vendor Program

It has been said that outcomes of total joint arthroplasty are 90% related to surgeon factors (such as prosthetic alignment and fit and soft-tissue management), and only 10% to the implant itself. Historically, surgeon choices of implants for primary total hip and total knee arthroplasty have been based on influences such as the prostheses used during training, prior vendor relationships, specific patient characteristics, and findings in published literature. Absent evidence that the selection of prosthesis vendor affects patient outcomes to any significant degree, and with the universal focus on lowering health care costs, surgeon implant/vendor preferences have come under close scrutiny.

In the August 7, 2019 issue of The Journal, Boylan et al. study the impact of a voluntary preferred single-vendor program at a large, high-volume, urban orthopaedic hospital with >40 (mostly hospital-employed) arthroplasty surgeons. The hospital’s use of hip and knee arthroplasty implants from the preferred vendor rose from 50% to 69% during the program’s first year. In addition, the mean cost per case of cases in which implants from the preferred vendor were used were 23% lower than the mean cost-per-case numbers from the previous year (p<0.001). Boylan et al. noted that low-volume surgeons adopted the initiative at a higher rate than high-volume surgeons, and that surgeons were more compliant with using the preferred vendor for total knee implants than for total hip implants.

Why is it that some higher-volume surgeons seem resistant to change? It is not clear from the data presented in this study whether the answer is familiarity with an instrument system, loyalty to local representatives, or relationships with manufacturers based on financial or personal connections. The authors observed that “collaboration between surgeons and administrators” was a critical success factor in their program, and interestingly, the 3 highest-volume surgeons in this study (who performed an average of ≥20 qualifying cases per month) all used total knee implants from the preferred vendor prior to the initiation of this program.

The provocative findings from this and similar studies lead to many questions ripe for further research. Because hospitals are highly motivated to reduce implant costs in the bundled-payment environment, preferred-vendor programs are gathering steam. We need to better understand how they work (or don’t) for specific surgeons, within surgical departments, and within hospital/insurance systems in order to evaluate their effects on patient outcomes and maximize any cost benefits.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Musculoskeletal Infection 2019

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Thomas K. Fehring, MD, co-author of the July 17, 2019 What’s New in Musculoskeletal Infection,” selected the five most clinically compelling findings—all focused on periprosthetic joint infection (PJI)—from among the more than 90 noteworthy studies summarized in the article.

Preventive Irrigation Solutions
–An in vitro study by Campbell et al.1 found that the chlorine-based Dakin solution forms potentially toxic precipitates when mixed with hydrogen peroxide and chlorhexidine. The authors recommend that surgeons not mix irrigation solutions in wounds during surgery.

PJI Diagnosis
–A clinical evaluation by Stone et al. showed that alpha-defensin levels in combination with synovial C-reactive protein had high sensitivity for PJI diagnosis, but the alpha-defensin biomarker can lead to false-positive results in the presence of metallosis and false-negative results in the presence of low-virulence organisms.

–In an investigation of next-generation molecular sequencing for diagnosis of PJI in synovial fluid and tissue, Tarabichi et al. found that in 28 revision cases considered to be infected, cultures were positive in only 61%, while next-generation sequencing was positive in 89%. However, next-generation sequencing also identified microbes in 25% of aseptic revisions that had negative cultures and in 35% of primary total joint arthroplasties. Identification of pathogens in cases considered to be aseptic is concerning and requires further research.

Treating PJI
–A multicenter study found that irrigation and debridement with component retention to treat PJI after total knee arthroplasty had a failure rate of 57% at 4 years.2

–Findings from an 80-patient study by Ford et al.3 challenge the assumption that 2-stage exchanges are highly successful. Fourteen (17.5%) of the patients in the study never underwent reimplantation, 30% had a serious complication, and of the 66 patients with a successful reimplantation, only 73% remained infection-free. Additionally 11% of the patients required a spacer exchange for persistent infection.

References

  1. Campbell ST, Goodnough LH, Bennett CG, Giori NJ. Antiseptics commonly used in total joint arthroplasty interact and may form toxic products. J Arthroplasty.2018 Mar;33(3):844-6. Epub 2017 Nov 11.
  2. Urish KL, Bullock AG, Kreger AM, Shah NB, Jeong K, Rothenberger SD; Infected Implant Consortium. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: treatment failure is high. J Arthroplasty.2018 Apr;33(4):1154-9. Epub 2017 Nov 21.
  3. Ford AN, Holzmeister AM, Rees HW, Belich PD. Characterization of outcomes of 2-stage exchange arthroplasty in the treatment of prosthetic joint infections. J Arthroplasty.2018 Jul;33(7S):S224-7. Epub 2018 Feb 17.

AI and Medical Ethics: The Minds Must Meet

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Artificial intelligence (AI) is no longer on the horizon; it is here and its number of “medical” applications, such as radiographic interpretation, is growing. Given the spectrum of potential uses of AI in medical decision making, consideration of medical ethics is essential, says Alan M. Reznik, MD, MBA in a recent AAOS Now article (see link below).

First, Dr. Reznik reviews the four basic elements of medical ethics:

  1. Autonomy—coercion-free independence of thought and decision making
  2. Justice—the assurance that the burdens and benefits of new or experimental treatments are distributed throughout all groups
  3. Beneficence—the intent of doing good for the patient
  4. Non-maleficence—the goal of doing no harm to the patient or society as a whole

Dr. Reznik goes on to observe that neural networks, the brains behind AI, have no inherent ethical reasoning. With the ability of neural networks to process massive amounts of human data, AI can and will “find and reinforce all preexisting biases in the dataset being used to ‘train’ it,” writes Dr. Reznik.

Here are 4 examples of why AI must conform to the four basic ideals of medical ethics:

Autonomy: The use of AI by insurance companies might yield fewer surgical approvals—saving carriers money, but denying individuals appropriate care. If that happens, “patient and physician autonomy will continue to be lost,” writes Dr. Reznik.

Justice: In AI-based epidemiology, the use of zip codes may introduce and/or amplify a wide range of socioeconomic, religious, and racial biases. AI applications that use addresses or zip codes “may need to be justified and checked for unethical bias each time they are used,” cautions Dr. Reznik.

Beneficence: Although “justice” might dictate decreased use of addresses, zip codes, and genetic information in AI-based medical applications, Dr. Reznik points out that to protect “beneficence” for individuals, some of that sensitive data will have to be included.

Nonmaleficence: The question here, Dr. Reznik writes, is “how AI will balance individual needs versus society and differing cultures in daily medical care.”

Reference

Click here to read Applying the Four Basic Principles of Medical Ethics to Artificial Intelligence

Delaying Knee Replacement: Driven to Distraction?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Some symptomatic patients with knee osteoarthritis (OA) present relatively early in the radiographic disease process, while others present after serious articular cartilage loss has occurred. In either case, young knee OA patients are often looking for ways to get relief while postponing a total knee arthroplasty (TKA).

One such recently introduced alternative is knee joint distraction (KJD), a joint-preserving surgery used for bicompartmental tibiofemoral knee osteoarthritis or unilateral OA with limited malalignment. Significant long-term clinical benefit as well as durable cartilage tissue repair have been reported in an open prospective study with 5 years of follow-up.1 A more recent study of distraction2 presents 2-year follow-up results of a 2-pronged trial that measured patient-reported outcomes, joint-space width (JSW), and systemic changes in biomarkers for collagen type-II synthesis and breakdown.

In one arm, end-stage knee OA patients who were candidates for TKA were randomized to KJD (n=20) or TKA (n=40). In the second arm, earlier-stage patients with medial compartment OA and a varus angle <10° were randomized to KJD (n=23) or high tibial osteotomy (HTO; n=46). In the distraction patients, the knee was distracted 5 mm for 6 weeks using external fixators with built-in springs, placed laterally and medially, and weight-bearing was encouraged. WOMAC scores and VAS pain scores were assessed at baseline and at 3, 6, 12, 18, and 24 months.

At 24 months, researchers found no significant differences between the KJD and HTO groups in that part of the trial. In the KJD/TKA arm, there was no difference in WOMAC scores between the two groups, but VAS scores were lower in the TKA group. The improvement in mean joint space width seen at one year in the KJD group of the KJD/TKA arm decreased by two years, though the values were still improved compared to baseline. However, the joint space width improvement seen at 1 year for both groups in the KJD/HTO arm persisted for two years. For all KJD patients, the ratio of biomarkers of synthesis over breakdown of collagen type-II was significantly decreased at 3 months but reversed to an increase between 9 and 24 months.

It is hard to believe that 6 weeks of joint distraction could trigger a process that yields such positive and long-lasting results. While much more research with longer follow-up is needed, KJD may prove particularly useful in younger knee OA patients trying to delay joint replacement.

References

  1. van der Woude, JAD, Wiegant, K, van Roermund, PM, Intema, F, Custers, RJH, Eckstein, F. Five-year follow-up of knee joint distraction: clinical benefit and cartilaginous tissue repair in an open uncontrolled prospective study. Cartilage. 2017;8:263-71.
  2. Jansen MP, Besselink NJ, van Heerwaarden RJ, Roel J.H. Custers1, Jan-Ton A.D. Van der Woude J-TAD, Wiegant K, Spruijt S, Emans PJ, van Roermund PM, Mastbergen SC, Lafeber FP. Knee joint distraction compared with high tibial osteotomy and total knee arthroplasty: two-year clinical, structural, and biomarker outcomes. ORS 2019 Annual Meeting Paper No. 0026 (Cartilage. 2019 Feb 13:1947603519828432. doi: 10.1177/1947603519828432. [Epub ahead of print])

“True Grit” Among Millennial Orthopaedists in Training

In a survey-based study published in the July 17, 2019 issue of The Journal of Bone & Joint Surgery, Samuelsen et al. made a hypothesis arising from a popularly held assumption about millennials: that orthopaedic residency applicants (predominantly millennials, with a mean age of 27.3) would have lower grit and self-control scores than attending orthopaedic surgeons (mean age of 51.3). The findings contradicted that hypothesis.

Surveys were completed by 655 (28%) of 2,342 attendings who received the questionnaire and by 455 (50.8%) of 895 orthopaedic residency applicants from the 2016-2017 resident match. The authors found that the residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p <0.01). When compared to the general population, residency applicants and attendings scored in the 70th and 65th percentiles of grit, respectively.

The American Heritage Dictionary defines “grit” as “indomitable spirit” or “pluck.” In the medical literature, where “grit” has received a lot of attention lately, the concept is defined as “steadfast passion and perseverance for long-term goals, especially in the setting of hardship and setbacks.” However grit is defined, Samuelson et al. say it “has consistently been proven to be associated with success in…medical environments.”

Three other interesting findings:

  • There were no significant differences in self-control or conscientiousness scores between the 2 groups.
  • Both age and number of years in practice were positively correlated with self-control scores in the practicing-surgeon group.
  • Among attending surgeons, the number of publications correlated with higher grit, self-control, and conscientiousness scores.

Samuelson et al. offer a possible explanation for the impressive grit scores among residency applicants: matching into orthopaedic residency has become increasingly competitive over the past several decades and “applicants to orthopaedic surgery…tend to represent the individuals at the top of their medical school classes.” Conversely, the authors suggest that grit, self-control, and conscientiousness scores could be used to identify applicants, residents, or junior staff “who are at risk for attrition during training or burnout in their careers.”

Having postulated that, however, the authors are quick to add that “it is unclear if [these findings] will be predictive of career success in the next generation of orthopaedists.”

Click here to see a 1-minute video commentary about these findings by Chad A. Krueger, MD, JBJS Deputy Editor for Social Media.

Study Supports Routine Patellar Resurfacing during TKA

The July 17, 2019 issue of The Journal features another investigation evaluating patellar resurfacing. Despite much research (see related OrthoBuzz post), this topic remains controversial among many total knee arthroplasty (TKA) surgeons. This study, by Vertullo et al., analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry. The findings suggest that routine resurfacing of the patella reduces the risk of revision surgery for TKA patients.

The authors evaluated more than 136,000 TKA procedures after placing the cases into three groups based on the surgeon’s patellar-resurfacing preference: infrequent (<10% of the time), selective (10% to 90% of the time), or routine (≥90% of the time). All of the cases evaluated utilized minimally stabilized components and cemented or hybrid fixation techniques, and they all were performed by surgeons who completed at least 50 TKAs per year.

The authors found that patients in the infrequent-resurfacing cohort had a nearly 500% increased risk of undergoing subsequent patellar revision during the first 1.5 years after TKA, compared to those in the routine-resurfacing cohort. Even more surprising to me was the finding that patients in the selective-resurfacing cohort had a >300% increased risk of needing a patellar revision within the first 1.5 years, compared to those in the routine-resurfacing cohort. In addition, the risk of all-cause revision was 20% higher in the selective cohort compared to the routine cohort.

What struck me most about this study were the differences between the selective and routine cohorts. One of the arguments against routine resurfacing of the patella is that surgeons should decide intra-operatively, on a patient-by-patient basis, whether the osteochondral health and biomechanics of the native patella warrant resurfacing. The findings of Vertullo et al. seem to call that reasoning into question. Although the results of this study add to the evidence supporting the routine resurfacing of the patella during TKA, I would like to reiterate a proviso from my earlier post on this topic: resurfacing is associated with added costs and an increased risk of potential complications.

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

New Minute-Commentary Video

Here’s what JBJS Deputy Editor for Social Media Chad Krueger, MD concludes after reading a survey-based study from the Department of Orthopaedic Surgery at the Mayo Clinic, comparing “grit” and self-control among orthopaedic residency applicants and practicing orthopaedists: