Confirmed: TXA Works Well in Adolescent Scoliosis Surgery

The evidence favoring tranexamic acid (TXA) for reducing surgical blood loss is ample and growing, but until now robust data were sparse regarding its efficacy in the setting of adolescent idiopathic scoliosis surgery. In the December 5, 2018 issue of The Journal of Bone & Joint Surgery, Goobie et al. report on a randomized, blinded, placebo-controlled trial showing that, in that population, TXA reduced perioperative blood loss by 27%, compared with blood loss in a placebo group.

Even with recent advances in scoliosis surgical technique, blood transfusions are common. And, because transfusions are associated with significant morbidity and mortality, limiting operative blood loss and reducing the need for transfusion have become focal points for orthopaedic surgeons.

In this Level-I trial, >100 patients between the ages of 10 and 18 years undergoing elective posterior instrumented spinal fusion were randomized to receive either TXA (infusion of a 50-mg/kg loading dose and a 10-mg/kg/h maintenance dose) or normal saline (delivered in the same way and dose) during surgery. The TXA group demonstrated an overall 27% reduction in cumulative blood loss and a 2-fold reduction in the percentage of patients with clinically relevant blood loss (defined as >20 mL/kg).

The cumulative effect of reduced blood loss was enhanced over time, with the positive effect of TXA being most evident in procedures lasting >4 hours. None of the patients in the TXA group required a transfusion or developed side effects such as thromboembolism or seizures.

In an interesting sidenote, the authors asked the participating orthopaedic surgeons, who were blinded to the randomization, to guess which group each patient had been assigned to by evaluating the relative ooziness of the surgical field. The surgeons guessed correctly 72% of the time.

Overall, these findings prompted the authors to conclude that “the use of TXA as part of a multimodal blood management strategy, as was employed in this study, should be considered the standard of care for patients undergoing surgery for adolescent idiopathic scoliosis.”

Using CT Data to Diagnose Osteoporosis

Osteoporosis is a “silent” disease, often becoming apparent only after a patient older than 50 sustains a low-energy fracture of the wrist, proximal humerus, or hip. Monitoring serum vitamin D levels and DEXA testing represent ideal screening methods to prevent these sentinel fragility fractures. In addition, through programs such as the AOA’s “Own the Bone” initiative, the orthopaedic community has taken a leadership role in diagnosing and treating osteoporosis after the disease presents as a fragility fracture. Own the Bone is active in all 50 states and, through local physician leadership, is identifying individuals who present with a fragility fracture so they can receive follow-up care that helps mitigate bone loss and prevent secondary fractures.

We still have a long way to go, however. Recent analyses show that only 30% of candidate patients (albeit up from 20%) are receiving this type of evidence-based care. The best-case scenario would be to identify at-risk men and women (osteoporosis does not affect women exclusively) before a potentially serious injury.

In the December 5, 2018 issue of The Journal, Anderson et al. present strong evidence that computed tomography (CT) can provide accurate data for diagnosing osteoporosis. CT is increasingly used (perhaps overused in some settings) across a spectrum of diagnostic investigations. The osseous-related data from these scans can be used to glean accurate information regarding a patient’s bone quality by analyzing the Hounsfield unit (HU) values of bone captured opportunistically by CT.  HU data are routinely ignored, but the values correlate strongly with bone mineral density, and they could help us recommend preventive care to our patients before a fragility fracture occurs. (For example, a threshold of <135 HU for the L1 vertebral body indicates a risk for osteoporosis.)

Orthopaedists should discuss the possibility of asking their radiologist colleagues who read CT scans of older patients to routinely share that data. When indicated, we could promptly refer patients back to their primary care provider for discussion of pharmacological treatment and lifestyle changes proven to help prevent primary fragility fractures. There is little doubt that our patients are getting older. Reviewing CT data  could help us dramatically improve preventive care and decrease the risk of first-time fragility fractures.

Click here for additional OrthoBuzz posts about fragility fractures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What’s New in Musculoskeletal Basic Science 2018

Every month, JBJS publishes a Specialty Update—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, Matthew J. Allen, VetMB, PhD, author of the December 5, 2018 Specialty Update on Musculoskeletal Basic Science, focuses on the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.

Gene Editing in Orthopaedics

–Gene-editing tools such as CRISPR-Cas9 have great potential as a means of introducing therapeutic genes into mesenchymal stem cells that can then be targeted to tissues in vivo. These researchers1 reported on genetically modified stem cells that have the potential to differentiate into chondrocytes encoding a natural inhibitor of interleukin-1, providing an opportunity for localized release of immunomodulatory factors.

Managing Orthopaedic Infections

–A novel study2 in which transmission electron microscopy was used to identify viable bacteria deep within the canalicular structure of cortical bone, remote from the site of an infected implant, suggests that effective debridement requires the removal of not just necrotic tissue, but also of adjacent, apparently unaffected bone.

Computational Modeling of Human Movement

–This report3 presented a human musculoskeletal model that provided extremely accurate predictions of ground reaction forces during simulated walking and squatting. As similar models are developed and validated, surgeons will have improved tools for evaluating patients, planning surgery, and making decisions about which procedure/implant is most appropriate for an individual patient.

Sex-Related Differences

–This report4 demonstrated sexually dimorphic regulation of gene-expression profiles in bone marrow osteoprogenitor cells that could partly explain clinical observations in sex differences in peak bone mass, bone remodeling, and immunomodulation.

Biological Enhancement of Ligament Healing

–Among several basic science papers focused on the optimal healing and durable fixation of tendons and ligaments, this notable work5 reported on the translation of bridge-enhanced ligament repair for the anterior cruciate ligament.

References

  1. Brunger JM, Zutshi A, Willard VP, Gersbach CA, Guilak F. CRISPR/Cas9 editing of murine induced pluripotent stem cells for engineering inflammation-resistant tissues. Arthritis Rheumatol.2017 May;69(5):1111-21. Epub 2017 Mar 31.
  2. de Mesy Bentley KL, Trombetta R, Nishitani K, Bello-Irizarry SN, Ninomiya M, Zhang L, Chung HL, McGrath JL, Daiss JL, Awad HA, Kates SL, Schwarz EM. Evidence of Staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis. J Bone Miner Res.2017 May;32(5):985-90. Epub 2017 Jan 26.
  3. Jung Y, Koo YJ, Koo S. Simultaneous estimation of ground reaction force and knee contact force during walking and squatting. Int J Precis Eng Manuf.2017;18(9):1263-8.
  4. Kot A, Zhong ZA, Zhang H, Lay YE, Lane NE, Yao W. Sex dimorphic regulation of osteoprogenitor progesterone in bone stromal cells. J Mol Endocrinol.2017 Nov;59(4):351-63. Epub 2017 Sep 4.
  5. Perrone GS, Proffen BL, Kiapour AM, Sieker JT, Fleming BC, Murray MM. Bench-to-bedside: bridge-enhanced anterior cruciate ligament repair. J Orthop Res.2017 Dec;35(12):2606-12. Epub 2017 Jul 9.

December 2018 Article Exchange with JOSPT

In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of December 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Perceptions of Rehabilitation and Return to Sport Among High School Athletes With Anterior Cruciate Ligament Reconstruction: A Qualitative Research Study.

In this cross-sectional study, researchers looked at 10 high-school-aged individuals who had undergone ACL reconstruction surgery and had not returned to sport. They found that psychosocial barriers to return to sport (e.g., persistent uncertainty about full recovery) were reported with greater consistency than physical barriers. The authors suggest that peer mentoring groups to facilitate psychosocial support during rehabilitation might help.

JBJS 100: Blount Disease, Low Back Pain

Under 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 full-text 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:

Tibia Vara: Osteochondrosis Deformans Tibia
WP Blount: JBJS, 1937 January; 19 (1): 1
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” strategies to treat this and other pediatric limb deformities.

Lumbar Disc Disorders and Low-back Pain: Socioeconomic Factors and Consequences
JN Katz: JBJS, 2006 April; 88 (Suppl 2): 21
The 21st century has brought with it a sharper focus on both the socioeconomic factors contributing to medical conditions and the socioeconomic consequences of those conditions. Back in 2006, Dr. Katz found that the total annual costs of low back pain in the US exceeded $100 billion, two-thirds of that  in the form of indirect costs (e.g., lost wages and reduced productivity). He also found that fewer than 5% of patients who have a low back pain episode account for 75% of the total costs, prompting Dr. Katz to emphasize the ongoing “critical importance of identifying strategies to prevent these disorders and their consequences.”

Unmasked: Predatory Publishers in Orthopaedics

It’s been more than a year since OrthoBuzz revisited the topic of predatory publishing (see related OrthoBuzz articles), but the comprehensive “Orthopaedic Forum” about this unsavory subject in the November 7, 2018 issue of JBJS warrants our attention.

In a meticulous investigation focused just on orthopaedic literature, Yan et al. found 104 suspected predatory publishers, representing 225 possible predatory journals. That’s nearly 3 times as many bogus publications as the 82 legitimate orthopaedic journals that the authors also identified. Somewhat disturbingly, 20 of the presumably predatory journals were also found to be indexed in PubMed.

The median article processing charge (APC) among predatory journals was $420, compared with $2,900 for legitimate journals. (Lower APCs tend to lure more researchers—especially younger ones—into the scams.) The most prevalent countries of origin of the predatory journals were India, the US, and the UK, while most of the authors publishing in predatory journals were from India, the US, the UK, and Japan. Predatory publishers are clearly taking advantage of the widespread pressure on researchers to publish as an avenue for career advancement.

The authors reiterate previously cited “red flags” that can tip off researchers to possibly predatory journals:

    • Very low article processing fees
    • Spelling and grammatical errors on the journal’s website
    • Overly broad scope
    • Language that targets authors more than readers
    • Promises of rapid publication
    • Dearth of information about copyright, retraction policies, or digital preservation

Yan et al. conclude that “ the scientific community needs to increase awareness of how to identify and avoid predatory journals. This is especially important for junior researchers…”

If you want more information about specific predatory journals, see Table II of the article (“List of Suspected Predatory Journals in the Field of Orthopaedics”), which includes the criteria that prompted the authors to categorize them as predatory.

Jason Miller, JBJS Executive Publisher
Lloyd Resnick, JBJS Developmental Editor

Will New Payment Models Adversely Affect Medicaid Patient Access to THA?

Concerns have arisen that the implementation of value-based, alternative payment models pegged to “bundled” episodes of care and/or patient outcomes may make it harder for a subset of patients to access the care they need. Specifically, some surgeons may be apprehensive to treat patients who have substantial medical comorbidities or socioeconomic situations that increase their risk of postsurgical complications and poor outcomes, because these alternative payment models often financially penalize physicians and hospitals for the cost of suboptimal results. The study by Shau et al. in the December 5, 2018 issue of The Journal provides data that sharpens the horns of this dilemma.

The authors used the National Readmissions Database to perform a propensity-score-matched comparison between >5,300 patients with Medicaid payer status who underwent a primary total hip arthroplasty (THA) and an equal number of patients with other types of insurance who also underwent primary THA.  Shau et al. found that Medicaid-covered THA patients had significantly increased overall readmission rates (28.8% vs 21%, p <0.001, relative risk=1.37), mean length of stay (4.5 vs 3.3 days, p <0.0001), and mean total cost of care ($71,110 vs $65,309, p <0.0001), relative to the other group.  These results strongly suggest that Medicaid payer status is an independent factor associated with increased resource utilization after total hip arthroplasty.

These findings can be viewed from a couple of different perspectives. First, from a preventive standpoint, surgeons and healthcare systems providing THA for Medicaid patients may need to spend more time preoperatively optimizing these patients (both physically and psychosocially) to decrease their postoperative resource burden and increase the likelihood of a good clinical outcome. Second, these results are further proof that any fair and effective alternative payment model needs to take into consideration factors such as Medicaid payer status and patient comorbidities. If they do not, such models will actually throw access barriers in front of patients in this demographic because providers may feel that caring for them increases the likelihood of being penalized financially.

Both perspectives are valid, so Medicaid payer status is a crucial factor to consider as alternative payment programs move forward. Nowadays, controlling costs is an important goal of any healthcare delivery system, but it must not lead to unintended discrimination in patient access to care. As we create further alternative payment models and refine existing ones, we must be careful not to prioritize cost cutting ahead of equitable patient access.

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

Preventing Acetabular Component Migration in Revision THA

Revision total hip arthroplasty (THA) is a challenging procedure for many reasons, not the least of which is the risk of aseptic loosening leading to re-revision, especially in patients with severe acetabular defects. Acetabular components made of porous tantalum have a developed a good reputation for lower rates of re-revision, relative to components made of other materials. In the November 21, 2018 issue of The Journal of Bone & Joint Surgery, Solomon et al. bolster the evidence base regarding the success of porous tantalum acetabular components in revision THA.

The authors conducted a single-center prospective cohort study that used radiostereometric analysis (RSA) to accurately measure acetabular component migration in 55 revision THAs that involved a porous tantalum acetabular component. Over a mean follow-up of 4 years, 48 of the 55 components migrated <1 mm, the threshold that, based on previous findings in the literature, the authors defined as predicting later loosening. Five of the 7 components that exceeded the threshold were re-revised for loosening related to patient symptoms.

The RSA data for the 5 components that required re-revision revealed large proximal translations and sagittal rotations that increased over time until re-revision, although the RSA  readings revealed that the majority of the migration occurred in the first 6 weeks. Among the components that did not exceed the 1 mm threshold for migration at 2 years, none have been subsequently re-revised for loosening.

The authors also analyzed fixation methods in this cohort. They found that, at 2 years, the median proximal translation of components that used inferior screw fixation was significantly lower than that of components without inferior screw fixation. The take-home messages from this study seem to be as follows:

  • Porous tantalum acetabular components really do perform well in revision THA.
  • When indicated, inferior screw fixation lowers the risk of component migration.
  • Early component migration is a good predictor of long-term component survivorship.

Guest Posts: Two Views on Gawande’s New Yorker Article about EMRs

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New Yorker article by Atul Gawande, the following two commentaries come from Matthew Christian, MD, and Paul Matuszewski, MD, respectively.

In his November 12, 2018 article in The New Yorker, Dr. Atul Gawande notes that more than 90% of American hospitals have been computerized in the past decade. In theory, that should make documentation easier, but Gawande cites a 2016 study revealing that most physicians now spend 2 hours documenting for every 1 hour of face-to-face patient interaction. That hit home to me when I joined a group practice that uses an electronic medical record (EMR) system for clinical documentation. One of my senior partners informed me that he spends 2 hours per day at home finishing clinic notes and dictations.

The downside of digitization seems clear. Dr. Gawande cites a study noting that primary care physicians screen positive for depression at a rate double that of the general population. A Mayo clinic study discovered that the amount of computer documentation was a strong predictor of physician burnout.

Gawande further describes medicine as a “complex adaptive system” that is “meant to evolve with time and changing conditions.” EMRs, conversely, seek to universalize and mandate best practices—often to a fault—with little or no flexibility. In Gawande’s adaptive model, computerization is “all selection and no mutation.”

What makes medicine so engaging and satisfying for me is treating each patient in a unique and personalized manner. It seems that the last bastion of the happy physician is the proceduralist, of which the orthopaedic surgeon is an example. We spend 2 or 3 fewer days a week documenting clinical visits and instead solve unique and intellectually challenging musculoskeletal problems. This break from a computer screen frees us to do the thing we have spent our whole adult lives training for—practicing medicine. That is, until the procedure is complete and we must log in to complete the operative notes, postop orders, attending attestation, and other seemingly endless tasks.

Matthew Christian, MD is an orthopaedic surgeon at OSS Health in York, Pennsylvania and a member of the JBJS Social Media Advisory Board.

*  *  *  *

The electronic medical record—a marvelous marriage of modern technology and medicine to improve care for patients. At least, that was the promise.  How it has played out over the past decade, however, leaves much to be desired from the perspective of physicians. Patient care has not been streamlined, and mounting evidence suggests that EMRs have increased the workload for physicians, adversely altered the physician-patient relationship, and increased the degree of physician burnout.1  Atul Gawande’s New Yorker article outlines his and other physician experiences with EMRs, concluding that many physicians—especially nonsurgeons bound to an office or clinic—now hate their computers.

But why? Gawande describes the evolution of EMRs from simple “cool” programs into complex, “very uncool” systems, eventually culminating in what former IBM software engineer Frederick Brooks described as the “Tar Pit.” That’s when a system becomes so complex and universalized for so many different people and functions (clinical and administrative in the case of EMRs) that it becomes the electronic equivalent of miles of bureaucratic red tape. For physicians, the “Tar Pit” means more clicks, more steps, more checks, more alerts and notifications—with little or no improvement for patients and less work/life balance for doctors.

Gawande relates the experience of a primary-care physician who once effectively maintained her own problem list for each of her patients. But the list has become in her words “utterly useless,” because now anyone across the organization can modify it, often inserting duplication and inaccuracies.  Computerized complexity that adds more work but little to no value discourages physicians from engaging with the system, compounding the problem.

Gawande’s article doesn’t go into detail about how we can solve this problem, but it presents several ways that physicians and hospital systems have coped. Some have resorted to medical scribes (often aspiring med students) or more highly trained overseas physicians who transcribe physician encounters. Some tech-savvy physicians expend effort to bend the software to their will – customizing components of the EMR despite pushback from vendors. This has led to various home-grown apps designed to help improve workflow and reduce hassles.

Time will tell whether these or other workarounds will actually help. One thing is certain, however. Unless physicians take charge and guide the design (and redesign) of EMR technology, the system will fail to serve the physician, and the current reality of the physician serving the system will persist.

Paul E. Matuszewski, MD is an assistant professor of orthopaedic traumatology and Director of Orthopaedic Trauma Research at the University of Kentucky School of Medicine and a member of the JBJS Social Media Advisory Board.

Reference

  1. Arndt et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017 (15) 5, 419-426
    Editor’s Note:
    The US Department of Health and Human Services has unveiled a draft plan to ease the burden of using EMR software. The draft strategy is open for public comments through January 28, 2019. Also, see this related OrthoBuzz Editor’s Choice post from JBJS Editor-in-Chief Dr. Marc Swiontkowski.

 

What’s New in Orthopaedic Rehabilitation 2018

Every month, JBJS publishes a Specialty Update—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, Nitin Jain, MD, MSPH, a co-author of the November 21, 2018 Specialty Update on Orthopaedic Rehabilitation, summarized the most clinically compelling findings from among the more than 40 noteworthy studies summarized in the article.

Acute Pain Management

–A randomized double-blind study comparing 4 two-way combinations of analgesics (three of which contained an opioid medication)1 in emergency-department patients experiencing acute extremity pain found no significant between-group differences in mean pain scores at 1 and 2 hours after medication administration.

Total Hip Arthroplasty

–A randomized clinical trial of >100 patients who underwent unilateral total hip arthroplasty found no significant differences in functional outcomes between a group that participated after surgery in a self-directed home exercise program and a group that participated in a standardized physical therapy program.

Concussion

–An assessment of brain tissue from 202 American football players2 whose organs were donated for neuropathological evaluation found that 87% had evidence of chronic traumatic encephalopathy (CTE). Analysis of brain tissue from former NFL players in the cohort showed that nearly all had severe CTE.

Rotator Cuff Tears

–A study following the natural progression of full-thickness, asymptomatic, degenerative rotator cuff tears found that patients with fatty muscle degeneration were more likely to experience tear-size progression than those without fatty infiltration.

Low Back Pain

–A study consolidating data from 3 separate randomized trials attempted to evaluate the efficacy of radiofrequency (RF) neurotomy for treating a heterogeneous collection of diagnoses that commonly result in low back pain.3 No significant or clinically important differences were found when the RF procedure was compared with a standardized exercise program. The number needed to treat for all 3 arms of the study ranged from 4 to 8, with a median of 5. Some have called into question the methods of this study, particularly the diagnostic criteria used for patient inclusion and the potential inaccuracy of lumping together heterogeneous diagnoses.

References

  1. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.
  2. Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, Alosco ML,Solomon TM, Nowinski CJ, McHale L, Cormier KA, Kubilus CA, Martin BM, Murphy L, Baugh CM, Montenigro PH, Chaisson CE, Tripodis Y, Kowall NW, Weuve J, McClean MD, Cantu RC,Goldstein LE, Katz DI, Stern RA, Stein TD, McKee AC. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017 Jul 25;318(4):360-70.
  3. Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68-81.