Archive | February 2014

Post-Rehab At-Home Exercise Boosts Mobility after Hip Fracture

A home-based exercise program modestly improved physical function in older adults who completed a standard rehabilitation program after a hip fracture, according to a recent JAMA study.

Half of nearly 200 older adults with limited function after finishing rehab were randomized to home exercises; the other half received in-home and phone-based nutrition education. The exercise group learned functional tasks (such as standing from a chair and climbing a step) during three hour-long home visits by a physical therapist, and then performed the tasks on their own three times weekly for six months. After six months, the exercise group had better scores of physical function — as measured by the Short Physical Performance Battery and Activity Measure for Post-Acute Care — than the control group.

While the clinical importance of these findings remains to be established, the results suggest that an extended period of structured at-home rehabilitation could help older patients sidestep some of the long-term functional limitations that often persist following a hip fracture.

Is Bone Regeneration Possible in Humans?

It’s a known fact that zebra fish have innate abilities to regenerate lost appendages and organs, but will researchers be able to crack the code that would make the same thing possible for humans? A recent paper published in Cell Reports shows how the two molecular pathways—the Wnt signaling pathway and the bone morphogenetic protein (BMP) pathway– work together in zebra fish to regenerate fins when they are amputated. University of Oregon (UO) researchers believe that understanding these signaling mechanisms in zebra fish could support the design of regenerative therapies that direct human cells to behave similarly.

According to a UO press release, “The researchers found that cell-to-cell signaling mediated by the Wnt pathway helps existing mature bone cells become progenitor cells after fin amputation.” Then the BMP pathway directs the newly formed cells to develop into functional bone cells. Humans have these same pathways, and defects in them are linked to human bone diseases.  Lead author Scott Stewart, PhD, said, “As we discover the cellular and molecular roles of the signals in zebra fish and pinpoint the missing network connections in mammals, maybe we could coax human bones to repair themselves equally as well.”

Read more here

Amputee Gets the Gift of ‘Feeling’ Again

Dennis Sorensen considers himself fortunate to get a chance that most amputees won’t get: to regain some natural sensation in his left hand. About 10 years ago, his left hand was amputated after a fireworks accident. He recently traveled to Rome to try an experimental prosthetic hand that added sensors to each finger. Then surgeons inserted tiny electrodes into Sorensen’s arm that connected the finger sensors to sensory nerves in his upper arm. Almost immediately, Sorensen was able to feel shapes, sizes, and textures of objects, and he was able to control the strength of his grip. Sorensen has spent almost a year testing the device, and the results of the experiment were reported in a recent issue of Science Translational Medicine.

Read more here

Four of Top 10 Most Costly Surgical Procedures are Orthopaedic

According to a statistical brief from the Agency for Healthcare Research and Quality, below are the top 10 costliest OR procedures performed in US hospitals during 2011. Aggregate annual costs are shown, followed by average per-stay costs in parentheses. Note that four of the 10 are orthopaedic procedures, with cardiac interventions coming in second, with three of the top 10.

1. Spinal fusion — $12.8 billion ($27,600 per hospital stay)
2. Knee replacement — $11.3 billion ($15,900 per hospital stay)
3. Percutaneous coronary angioplasty — $9.7 billion ($18,800 per hospital stay)
4. Hip replacement — $8 billion ($17,200 per hospital stay)
5. Caesarean section — $7.5 billion ($5,900 per hospital stay)
6. Colorectal resection — $6.7 billion ($23,400 per hospital stay)
7. Coronary artery bypass graft — $6.4 billion ($38,700 per hospital stay)
8. Heart valve procedures — $6.1 billion ($53,400 per hospital stay)
9. Cholecystectomy and common duct exploration — $5 billion ($12,600 per hospital stay)
10. Treatment, fracture or dislocation of hip and femur — $4.3 billion ($16,800 per hospital stay)

Twitter Popularity Low Among Orthopaedic Surgeons

Results from a new JBJS study, Mobile Technology/Social Media Usage Among Orthopaedic Surgeons, show that 8% of orthopaedic surgeons are using Twitter for professional purposes, and only 6% of surgeons find Twitter helpful. Although usage of Twitter is relatively low, a handful of surgeons follow specific Twitter feeds with high degrees of loyalty.

TwitterFeeds Graphic

Stage 3 Meaningful Use Plans Are on the Table

A workgroup has submitted draft recommendations for Stage 3 Meaningful Use incentives. Chaired by Paul Tang, MD, the workgroup has put forth various policy ideas over the past 2 years.  One proposal would have physicians and hospitals use clinical decision support interventions based on four of six high-priority objectives: preventive care, chronic disease management, appropriateness of lab/rad orders, medication-related decision support, medication and allergy lists, and drug-drug and drug-allergy checks. The workgroup has also proposed new certification standards for electronic health records (EHR) that would make it easier for patients to modify their records online.

A Reminder about What Orthopaedic Surgeons Should Not Do

The Choosing Wisely campaign seeks to bring more awareness to tests and procedures that should be discussed between physicians and patients. The campaign was spearheaded by the ABIM Foundation, and the American Academy of Orthopaedic Surgeons (AAOS) partnered with the campaign to develop a list of the five things physicians and patients should question.

  1. Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
  2. Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.
  3. Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
  4. Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
  5. Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.

The list was developed after review of approved clinical practice guidelines and included input from specialty society leaders.

The Subliminal Psychology behind Ordering Tests

Medical tests have come under close scrutiny in this era of health care cost containment. Test over-ordering is thought to arise largely from the practice of defensive medicine, but Victoria Shaffer, assistant professor of health sciences at the University of Missouri School of Health Professions, has a different hypothesis and has been researching how doctors make test-ordering decisions. In a study published in Health Psychology Shaffer, human factors engineer Adam Probst, and pediatrician Raymond Chan, MD, examined the relationship between how tests are displayed in EMR systems and the number that are ordered.

The study looked at three different ways tests are displayed on electronic health records — one presented tests unchecked by default where the physician had to check the test to be done (opt-in format); one showed tests preselected which had to be unchecked (opt-out tests); and a third showed a few pre-selected tests.  The results of this study corroborated Shaffer’s hunch — more tests were ordered when doctors had to opt-out. She thinks the use of opt-in defaults would result in better care for patients and lower costs.

Caring for Caregivers Was Key After Marathon Bombing

Events like the 2013 Boston Marathon bombing can have a tremendous emotional impact on any care provider—physicians, nurses, imaging techs, registration and administrative personnel, transporters, and housekeeping staff. “The solution is not to tell people to ‘suck it up,’” insisted Ron Walls, MD, chair of the Department of Emergency Medicine at Brigham and Women’s Hospital.

Many of the stories in It Takes a Team—The 2013 Boston Marathon, a new Special Report jointly published by JBJS and JOSPT, emphasize the importance of caring for the caregivers–making sure the basic physical and emotional needs of clinicians are met so they can do their jobs of caring for others.

It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day (Tufts Medical Center, Beth Israel Deaconess Medical Center, Brigham and Women’s, Boston Medical Center, and Mass General) ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients.

Not a single bombing victim who reached a hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. But the lives that were given back to the survivors had changed forever—along with the lives of the clinicians who cared for them. Everyone directly exposed to the Marathon trauma will have emotional ups and downs, and those who seemed unaffected early on may develop problems later. So caring for the caregivers will be an ongoing obligation.

It Takes a Team—The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event is divided into three parts:

Part 1: Readiness—Fortune Favors Prepared Teams

Part 2: Response and Recovery—April 15 Through December 31

Part 3: The Road Ahead—A Long Haul for Each and All

Download a PDF of the full report.

Editor’s Choice – March 3, 2014

Orthopaedic surgeons are frequently asked if the metal devices that they implant induce hypersensitivity reactions. In addition, during the workup of a patient who has an infection at the site of a loose prosthesis, the question of hypersensitivity reaction is frequently raised. Metal hypersensitivity, as detected with skin patch testing, is common. Several sources have suggested that the prevalence of metal hypersensitivity is between 10% and 17% in the general population. However, there is only anecdotal evidence that deep-seated metal implants may induce cutaneous sensitivity reactions.

In the February 2014 issue of JBJS Reviews, Razak et al. consider conventional arthroplasty implants (metal-on-polyethylene and metal-on-ceramic articulations) and fracture fixation devices. Their article does not address metal-on-metal arthroplasty, although they do consider articulating implants and the local and systemic levels of metal ions that they produce. The authors point out that, when considering metal hypersensitivity, it is important to distinguish between cutaneous contact sensitivity and sensitivity to deep-seated implanted devices.

Cutaneous hypersensitivity reactions to metal are mediated by activation of the immune system and can be divided into four types. Type-III reactions are antibody-mediated, and Type-IV reactions are cell-mediated. Identifying cutaneous metal hypersensitivity involves self-reporting, patch testing, dry metal tapping, subcutaneous metal implantation, lymphocyte transformation tests, and leukocyte migration inhibition tests.

Hypersensitivity to deep-seated implants is different. Conventional orthopaedic implants are usually made of alloys (mixtures of several metals), such as cobalt-chromium, stainless steel, titanium, and zirconium alloys. These alloys contain traces of other metals such as nickel, aluminum, and molybdenum. These deeply implanted metallic materials may corrode chemically or mechanically, resulting in the release of metal debris and ions that may combine with native proteins to form larger complexes. These larger complexes may then be taken up and presented by antigen-presenting cells.

As noted by Razak et al., there does not seem to be strong evidence supporting or disputing the role of metal hypersensitivity in the development of aseptic loosening, deep local reactions, or ongoing pain in patients with deep-seated implants. The levels of metal ions that are released vary between articulating and non-articulating implants, and there is a paucity of data to address the question of their role in the aseptic loosening process. Malfunctioning articulating implants can release high levels of metal ions, and fracture fixation devices are less likely to generate the same amount of metal ions as conventional arthroplasty implants. Therefore, the likelihood that fracture fixation devices are at play in the hypersensitivity process seems small.

On the basis of the data presented in this article, it remains unclear what role metal hypersensitivity plays in patient symptomatology, implant failure, or implant loosening. However, certain considerations should be taken into account when one is faced with a patient who is about to undergo orthopaedic surgery involving the use of a metal implant and who has a history or a question regarding sensitivity to metal. While several approaches can be used, most involve the use of patch testing at some point, despite the fact that this test is costly ($80.00 per kit in the United States).

Razak et al. recommend that, when the use of an orthopaedic metal implant is being considered, the patient should be counseled, as part of the consent process, with regard to the small risk of potential reactions to metal, the risk of ongoing symptoms and aseptic loosening, and the limitations in our understanding of the mechanisms that account for metal hypersensitivity reactions. In the rare case in which a patient reports a substantial localized reaction (such as blistering, hives, or extensive rash) or a systemic cutaneous reaction to metal, patch testing is recommended. Such patch testing should include components of potential implants such as stainless steel, cobalt-chromium, or titanium-zirconium.

To our knowledge, there have been no randomized controlled trials comparing stainless steel or cobalt-chromium implants with identical implants made of titanium or zirconium, so the need to provide high-quality evidence regarding the effects of implant materials on clinical outcomes is important. However, what is really needed is the development of tests that will reliably identify individuals who are prone to a response to a deep-seated metal implant, and these tests are simply not available.