Hip dislocation is one of the most common perioperative complications of total hip arthroplasty (THA). The latest “Case Connections” article examines an often-overlooked spinal basis for THA dislocations, 2 cases of dual-mobility hip-bearing dissociations during attempted closed reduction for post-THA dislocations, and a unique application of Ilizarov distraction to treat a chronic post-THA dislocation.
The springboard case report, from the February 22, 2017, edition of JBJS Case Connector, describes the case of a 63-year-old woman who had experienced 4 anterior dislocations in less than 3 years after having her left hip replaced. Each dislocation was accompanied by lower back pain, and the patient also reported substantial pain in the contralateral hip. The authors emphasize the importance of recognizing pelvic retroversion and sagittal spinal imbalance before performing total hip arthroplasty.
Two additional JBJS Case Connector case reports summarized in the article focus on:
- The risks of performing closed reduction on patients with a dislocated dual-mobility hip design.
- A unique application of Ilizarov distraction to lengthen soft tissues for femoral-component reduction in a patient with a chronically dislocated hip replacement.
While closed reduction with the patient under sedation is a frequently employed first-line tactic that is often successful for dislocated THAs, these 3 cases show that creative surgical interventions may be necessary for optimal outcomes in patients with “complicated” hips and/or recurrent dislocations.
In the February 15, 2017 issue of The Journal, Aneja et al. utilize a large administrative database to examine the critical question of venous thromboembolism (VTE) risk as it relates to managing patients with metastatic femoral lesions. The authors found that prophylactic intramedullary (IM) nailing clearly resulted in a higher risk of both pulmonary embolism and deep-vein thrombosis, relative to IM nailing after a pathologic fracture. Conversely, the study found that patients managed with fixation after a pathological fracture had greater need for blood transfusions, higher rates of postoperative urinary tract infections, and a decreased likelihood of being discharged to home.
The VTE findings make complete clinical sense, because when we ream an intact bone, the highly pressurized medullary canal forces coagulation factors into the peripheral circulation. When we ream after a fracture, the pressures are much lower, and neither the coagulation factors nor components of the metastatic lesion are forced into the peripheral circulation as efficiently, although some may partially escape through the fracture site.
One might conclude that we should never consider prophylactic fixation in the case of metastatic disease in long bones, but that would not be a patient-centric position to hold. In my opinion, the decision about whether to prophylactically internally fix an impending pathologic fracture should be based on patient symptoms and consultations with the patient’s oncologist and radiation therapist.
If all of the findings from Aneja et al. are considered, and if the patient’s symptoms are functionally limiting after initiation of appropriate radiation and chemotherapy, prophylactic fixation should be performed, along with vigilantly managed VTE-prevention measures. This study is ideally suited to inform these discussions for optimum patient care.
Marc Swiontkowski, MD
On Thursday, February 23, 2017, at 6:00 pm EST, the Own the Bone initiative will offer a webinar titled “Atypical Fractures and Osteoporosis Medication Considerations”
James Goulet, MD, from the University of Michigan, will discuss atypical fractures and other rare outcomes of the use of osteoporosis medication, including what to look for and how to treat these occurrences. He will also address drug holidays, and how and when to continue treatment on these complex cases.
The American Orthopaedic Association (AOA) developed Own the Bone as a quality improvement program to address the osteoporosis treatment gap and prevent subsequent fragility fractures.
0.75 hour of CME credit is available.
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, Gwo-Chin Lee, MD, author of the January 18, 2017 Specialty Update on Adult Reconstructive Knee Surgery, selected the five most clinically compelling findings from among the more than 100 studies summarized in the Specialty Update.
Nonoperative Knee OA Treatment
—Weight loss is one popular nonoperative recommendation for treating symptoms of knee osteoarthritis (OA). An analysis of data from the Osteoarthritis Initiative found that delayed progression of cartilage degeneration, as revealed on MRI and clinical symptoms, positively correlated with BMI reductions >10% over 48 months.1
Total Knee Arthroplasty
—In total knee arthroplasty (TKA), the drive toward producing normal anatomy has led to explorations of alternative alignment paradigms. A prospective randomized study found that small deviations from the traditional mechanical axis (known as kinematic alignment) can be well tolerated and do not lead to decreased survivorship or poorer functional outcomes at short-term follow up.2
—Controversy exists about the optimal method to achieve stemmed implant fixation in revision TKA. A randomized controlled trial of TKA patients with mild to moderate tibial bone loss found no difference in tibial implant micromotion between cemented and hybrid press-fit stem designs, based on radiostereometric analysis.
Blood Management in TKA
—Minimizing blood loss and transfusions is crucial to minimizing complications after TKA. A randomized, double-blind, placebo-controlled trial found that intra-articular and intravenous administration of tranexamic acid (TXA) was more effective than intravenous TXA alone, without an increased risk of venous thromboembolism (VTE). However, the optimal regimen for TXA remains undefined.
—VTE prophylaxis is essential for all patients undergoing TKA. A risk-stratification study of pulmonary embolism (PE) after elective total joint arthroplasty reported that the incidence of PE within 30 days after either hip or knee replacement was 0.5%. Risk factors associated with PE were age of > 70 years, female sex, and higher BMI. The presence of anemia was protective against PE. The authors developed an easy-to-use scoring system to determine risk for VTE to help guide chemical prophylaxis.3
- Gersing AS, Solka M, Joseph GB, Schwaiger BJ, Heilmeier U, Feuerriegel G, Nevitt MC, McCulloch CE,Link TM. Progression of cartilage degeneration and clinical symptoms in obese and overweight individuals is dependent on the amount of weight loss: 48-month data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2016 Jul;24(7):1126-34. Epub 2016 Jan 30.
- Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M. PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 27. [Epub ahead of print]
- Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and validation of a risk stratification system for pulmonary embolism after elective primary total joint arthroplasty. J Arthroplasty. 2016 Sep;31(9)(Suppl):187-91. Epub 2016 Mar 17.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Almost 50 years ago, in a classic 1968 JBJS paper, Leon Wiltse and co-authors described a novel and innovative access route to the lumbar spine. At that time, the vast majority of approaches to the lumbar spine were performed through midline incisions. Wiltse´s approach, however, utilized a more lateral access route to the spine. In this beautifully illustrated paper, the authors described a curved incision of the fascia and the skin with direct access to the transverse processes, pedicles, and the lateral masses.
The advantages of this novel access were multifold. Although wide midline laminectomies represented the gold-standard decompression technique at that time, the lateral approach served to avoid a more challenging and risky midline revision access, adding an elegant access for salvage procedures. Two goals of Wiltse’s approach were to achieve solid, posterolateral fusions and to decompress the neural structures. Graft harvest from the posterior iliac crest was easily facilitated with this approach.
Additional advantages included reduced blood loss and less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments, which served to maintain the stability of the lumbar spine. The main downside was the necessity of performing two skin incisions as opposed to just one midline incision.
Since its introduction, Wiltse´s approach and the anatomic planes have been studied in great detail.1,2 Considering the vast developments in spine surgery over the last years and decades, the Wiltse approach has stood the test of time, as it still represents one of the main access routes to the lumbar spine that any skilled spine surgeon needs to master.
With the arrival of instrumentation, Wiltse´s approach was later employed in interbody fusion and minimally invasive transforaminal lumbar interbody fusion (TLIF) techniques, as it allowed direct access to the pedicles and the disc space. It has also been used for various techniques of direct pars repair.3
With the addition of some minor modifications, Wiltse´s approach still reflects the main access for minimally invasive, microsurgical treatment of foraminal and extraforaminal disc herniations, including bony decompression of the neuroforamen.4 The far lateral access permits sufficient decompression of the exiting nerve roots while preserving the facet joints, which serves to avoid more invasive fusion techniques for a considerable number of patients.
Overall, Wiltse´s innovative approach advanced spinal care by reducing access–related morbidity. Dr. Wiltse passed away at age 92 in 2005. His major achievements in spine surgery and his great accomplishments will remain in our memories and will continue to impact spine surgery over the coming decades.
Christoph J. Siepe, MD
JBJS Deputy Editor
- Vialle R, Court C, Khouri N, et al. Anatomical study of the paraspinal approach to the lumbar spine. Eur Spine J. 2005;14(4):366-71.
- Palmer DK, Allen JL, Williams PA, et al. Multilevel magnetic resonance imaging analysis of multifidus-longissimus cleavage planes in the lumbar spine and potential clinical applications to Wiltse’s paraspinal approach. Spine (Phila Pa 1976). 2011;36(16):1263-7.
- Xing R, Dou Q, Li X, et al. Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery. Spine (Phila Pa 1976). 2016;41(8):E494-502.
- Mehren C, Siepe CJ. Neuroforaminal decompression and intra-/extraforaminal discectomy via a paraspinal muscle-splitting approach. Eur Spine J. 2016.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD.
With 6 months left in my trauma fellowship, the excitement, anticipation, and sometimes terror around finally beginning my young career continues to build. However, on a flight back from the recent AOTrauma Fellows Course, I also became equally excited (but not so terrified) about the opportunity to start paying it forward.
Being surrounded by some of the best minds in orthopaedic trauma, both young and seasoned, was not only a boost for our clinical acumen, but more importantly was also inspirational. I experienced first-hand the faculty’s dedication to teaching the next generation. Taking time away from their families, their patients, and their institutions, the AOTrauma faculty truly exemplified the role of “educators.” By discussing their experiences—with us and with one another—I saw yet again that life-long learning is very real, and it’s how you continue to get better everyday.
I am not writing about this recent experience to promote a specific organization, but rather to remind my generation of young surgeons that soon it will be our turn to pay it forward by filling the big shoes of mentorship, education, and leadership.
No matter what your specialty is, if you have not done so already, I urge you to join your respective organizations and get involved in some capacity. To echo the words of my own mentor, Frank Liporace, MD, “No one is asking you to run the entire thing, but trust me, in whatever capacity you participate, you will definitely learn something to get you better, and in the end, you will find a network of friends who become family.”
In 2017, the “family” of orthopaedic professionals is growing larger, more specialized, and more interconnected and accessible than ever. Our orthopaedic family continues to push the field forward, finding new ways to educate, research, and improve patient care.
So I urge my classmates of talented individuals: please honor those teachers and mentors who have enriched our lives. Let’s pay it forward, continue to work hard, and try to stay involved, because one day, we will need another generation to do the same for us.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
The February 1, 2017 issue of JBJS contains the fourth of a series of personal essays in which orthopaedic clinicians tell a story about a high-impact lesson they learned that has altered their worldview, enhanced them personally, and positively affected the care they provide as orthopaedic
This “What’s Important” piece comes from Dr. Chad Krueger of the Womack Army Medical Center. In his essay titled “Being Present,” Dr. Krueger emphasizes that family and friends are too easily taken for granted amid clinical and research demands.
If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.
Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.
It is well accepted that kids with Legg-Calve-Perthes (LCP) disease do best when their condition is diagnosed and managed before 6 years of age. Surgical treatment is often recommended for children 6 years and older who have more severe femoral-head involvement, and orthopaedists perform combined pelvic and femoral varus osteotomies on some of those children.
In the February 1, 2107 edition of The Journal, Mosow et al. compare 10-year outcomes in 52 LCP patients who underwent combined osteotomies (mean age at surgery of 7.9 years) with results reported in the literature for single pelvic or femoral osteotomies. Although the postoperative radiographic and functional results after combined osteotomy were good, they were overall no better than those reported in the literature for either osteotomy alone.
The authors admit that in the absence of a randomized study design, these findings should be interpreted with caution, but they conclude that “it is not recommended that combined osteotomies for this age group routinely be used.”
In the February 1, 2017 edition of The Journal, Deren et al. provide an important analysis of muscle mass as it relates to mortality in older patients with an acetabular fracture. Among 99 fracture patients studied retrospectively, 42% had sarcopenia, defined in this study as a skeletal muscle index at the L3 vertebral body of <55.4 cm2/m2 for men and <38.5 cm2/m2 for women.
Deren et al. found that low BMI was associated with sarcopenia and that patients with sarcopenia were significantly more likely than patients without sarcopenia to sustain their skeletal injury from a low-energy mechanism. Sarcopenia was also associated with a higher risk of 1-year mortality, especially when in-hospital deaths were excluded. While the authors note that there’s no consensus definition for clinically diagnosing sarcopenia, they conclude that “sarcopenia based on the skeletal muscle index may be a better predictor of mortality than other commonly used classification
There are important subtextual messages in this study for all physicians who manage geriatric patients. Maintenance of muscle mass by resistance exercise (lifting weights, isometrics, etc.) is of critical importance in limiting fall risk and maintaining good balance and bone density. Dietary considerations are intertwined with exercise in maintaining muscle mass among older patients. Resistance training and cardio exercise help to maintain appetite, and adequate protein intake is of utmost importance. When families and medical teams work together, the risk of sarcopenia can be minimized, resulting in lower rates of falls, fewer low-energy fractures, and less mortality.
Marc Swiontkowski, MD
The recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.
Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of February 2017:
Comparison of Highly Cross-Linked and Conventional Polyethylene in Posterior Cruciate-Substituting Total Knee Arthroplasty in the Same Patients
What’s New in Adult Reconstructive Knee Surgery
Hinged External Fixation in the Treatment of Knee Dislocations: A Prospective Randomized Study
A Randomized, Controlled, Prospective Study Evaluating the Effect of Patellar Eversion on Functional Outcomes in Primary Total Knee Arthroplasty
Comparison of Functional Outcome Measures After ACL Reconstruction in Competitive Soccer Players: A Randomized Trial
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.