In the November 4, 2015 Level I JBJS study by Kukkonen et al., patients over the age of 55 were randomized to one of three treatment arms for management of a rotator cuff tear—physical therapy alone and acromioplasty with and without rotator cuff repair. We learn that over a two-year follow up, treatment with physiotherapy produced results as clinically favorable as surgery in this “older” age group, although tear size was significantly smaller in the repair group than in the other two.
As Dr. Ken Yamaguchi points out in his commentary on the study, the average patient age for surgical repair of a rotator cuff tear is currently the mid-50s, and we know that the likelihood of repair failure with lack of healing increases in patients beyond their mid-60s. In fact, historic post-mortem studies have identified rotator cuff tears in 70% to 80% of all subjects, making this is a common wear-and-tear phenomenon among humans, akin to degenerative disc disease and declining hearing and vision.
So is the take-home message from Kukkonen et al. that any patient over the age of 55 should be treated with physiotherapy, with no discussion of surgical repair? I think not. The message is that we should be more supportive of a decision to start down the physiotherapy path with patients in their mid-50s than ones in their mid-40s. Although this study emphasizes the age factor, we should also remember that age is only one data point in a shared decision making discussion. An athletic, fit woman in her mid-50s who participates in yoga and zumba four days a week in addition to resistance training is a very different patient than the sedentary, deconditioned woman of the same age.
In the discussion of what is best for each patient, we need to leverage our knowledge regarding the musculoskeletal problem coupled with the wisdom to consider each patient’s functional demands and goals for activity return. As our population ages and the level of older-patient fitness hopefully increases, these discussions will take more time, but will result in higher-quality decisions for the individual patient.
Marc Swiontkowski, MD
On Thursday, December 10, 2015, from 6:00 to 6:30pm EDT, the Own the Bone initiative will offer a free webinar titled “Vitamin D in Chaos: A Common Sense Approach for Orthopaedics.”
Neil C. Binkley, MD, from the University of Wisconsin will review the physiology of vitamin D, current approaches to 25(OH)D testing, and recommendations for treatment of those whose levels are low. Defining “low” vitamin D status remains extremely controversial, but many fracture patients have vitamin D inadequacy that may contribute to low bone mass and fragility fracture risk.
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.
Fractures of the femoral head are uncommon. Typically associated with hip dislocations, they are found in association with high-energy trauma. They occur more commonly in men than women. Because of their relatively rare occurrence, large series with validated outcomes have not been reported. As noted by Marecek et al. in the November 2015 issue of JBJS Reviews, the goals of treatment are to achieve early and safe reduction and fixation and, in doing so, avoid complications, including osteonecrosis and heterotopic ossification.
To accomplish these goals, it is important to identify any associated life-threatening injuries and to achieve prompt reduction. A distinction is made between infrafoveal and suprafoveal fractures and the presence of associated femoral neck or acetabular fractures. Operative treatment is usually accomplished through the direct anterior or surgical hip dislocation approach, depending on the associated injury patterns. The use of mini-fragment lag screw fixation is generally preferred.
The initial treatment of femoral head fractures follows advanced trauma life support (ATLS) protocols. If hip dislocation is present, urgent reduction is performed in conjunction with skeletal relaxation to decrease the risk of osteonecrosis of the hip. Nonoperative treatment is reserved for patients with infrafoveal fractures with a concentric hip joint and no intra-articular debris and patients in whom operative intervention carries a morbid risk of complications. The timing of intervention for femoral head fractures remains controversial, and at least one randomized controlled trial demonstrated significantly worse outcomes for patients who had closed manipulative reduction and delayed open reduction and internal fixation compared with patients who received immediate operative reduction and fixation.
In summary, femoral head fractures are uncommon but severe. After prompt reduction of hip dislocations, a thorough evaluation is required to detect all associated injuries and to formulate an appropriate operative plan. Treatment should be directed toward achieving a stable, concentrically reduced hip with anatomic reduction of the fracture or excision of comminution and removal of articular debris. Arthroplasty should be reserved for patients who are older, those who have degenerative changes of the hip, and those who have complex injuries, the treatment of which would be more detrimental or risky than immediate arthroplasty.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
The contributions to the field of shoulder surgery from Dr. Charles Neer are too numerous to document in any one commentary. A partial list would include shoulder arthroplasty (both hemi and total), the concept of impingement and acromial pathology, multidirectional instability, and the role of the AC joint in rotator cuff pathology.
Dr. Neer also made numerous contributions to the understanding of fracture care, including the distal femur and clavicle. But no area of fracture management was of greater interest to him and his colleagues at Columbia than the proximal humerus. This classic manuscript has been cited thousands of time and remains the seminal piece in the foundation of understanding fracture patterns in the proximal humerus—and the attendant treatment implications.
Dr. Neer introduced the concept of the four parts of the proximal humerus in this manuscript, and with it the implication of isolating the humeral-head blood supply in a four-part fracture. The impetus to understand the complication of avascular necrosis of the humeral head began with this manuscript, as did the critical debates regarding surgical versus nonsurgical intervention and replace-or-fix. An important area of ongoing debate is Neer’s definition of a “displaced” fracture in the proximal humerus as having > 1 cm of displacement. The orthopaedic community to this day is wrestling with this definition and its relevance to treatment and outcomes.
This classic manuscript also helped launch a decades-old conversation about the role of fracture or musculoskeletal-disease classification systems. Subsequent publications by Zuckerman and Gerber identified issues with inter- and intra-rater reliability when applying the Neer classification system to a set of radiographs. The reliability debate surrounding this classification system led us to understand the issue of forcing continuous variables (fracture lines are infinite in their trajectory and displacement) into dichotomous variables (a classification system). Because of Dr. Neer’s work and subsequent research, our community understands that when we make these classification designations, we will agree about 60% of the time (kappa statistic of 0.6). That level of agreement is not reflective of a “good” or “bad” classification system; rather, it’s a consequence of moving a continuous variable to a dichotomous variable.
So we remain indebted to Dr. Neer not only for laying the foundation for the treatment of patients with proximal humeral fractures, but also for vastly expanding our knowledge regarding the role, strengths, and weaknesses of disease and fracture-classification systems.
Marc Swiontkowski, MD
The rate of graft failure following anatomic ACL reconstruction has been reported to be as high as 13%, nearly double the reported failure rate of transtibial reconstructions. The majority of anatomic graft failures occur six to nine months after surgery, when patients commonly return to full sports activity. Findings from a cadaver study by Araujo et al. in the November 4, 2015 edition of The Journal of Bone & Joint Surgery may help explain these phenomena.
The authors used a robotic system to measure in situ forces on 12 native cadaver ACLs and on three different reconstructions, one representing the anatomic approach and two reconstructions approximating traditional transtibial approaches. They measured forces on the grafts during anterior tibial loading and simulated pivot-shift loading.
Araujo et al. hypothesized that an anatomically positioned graft would experience increased in situ forces relative to transtibial positioning, and that is what the study revealed during knee flexion angles of 0°, 15°, and 30°. At 45°, 60°, and 90° of flexion, the transtibially positioned grafts experienced higher in situ loading forces than the anatomic ones.
While this cadaveric study is not the definitive word on this matter, with the high graft forces on the anatomic reconstructions, the authors suggest that “rehabilitation and return to sports progression may need to be modified to protect an anatomically placed graft after ACL reconstruction.”