JBJS Reviews Editor’s Choice–Team Approach to Diabetic Foot Ulcers
One of the newest features from JBJS Reviews is the “Team Approach” article. Team Approach articles highlight the individual and collective importance of the multiple physician and nonphysician providers who are involved in the care of a patient. Determining how the multidisciplinary interactions and contributions are key to the understanding of a medical condition and its treatment can be essential to a successful musculoskeletal health process.
In the July 2016 issue of JBJS Reviews, Pinzur et al. describe the team approach to the treatment of diabetic foot ulcers. The authors note that an estimated 29.1 million people in the U.S. have diabetes and that, at any point in time, 3% to 4% have a foot ulcer, both of which are sobering statistics. Diabetic foot ulcers and their associated infections lead to >70,000 lower-extremity amputations yearly. Between one-third and one-half of diabetic patients undergoing major lower-extremity amputation will die within 2 years after the amputation. In order to most effectively deal with this devastating outcome, a team approach with multidisciplinary involvement is needed.
It is now accepted that the best-performing health systems are those that address challenges by developing a strategy of population management in which patients with resource-consuming medical conditions receive care across multiple medical disciplines. This strategy begins with the identification of modifiable risk factors. The most efficient patient-safety methodology for avoiding complications following surgery is to operate on healthier patients. Indeed, if we look at our orthopaedic trauma colleagues as an example, we see that survival rates and patient outcomes following hip fracture have improved since the development of systems that rapidly optimize patients prior to operative repair. This experience has taught us how important it is to have a hospitalist co-managing our orthopaedic patients. Similarly, our arthroplasty colleagues have learned that outcomes are worse and complications rates are increased in patients who have multiple medical comorbidities. Prior to urgent surgery, many of these medical conditions can be stabilized. Thus, the most proactive health systems are those that use interventions to identify and minimize health risk. When modifiable risk factors are improved, patient safety is improved.
Pinzur et al. reintroduce the concept of the so-called diabetic educator. The responsibilities of the modern diabetic educator have progressed from simple patient education on diet, glycemic control, and lifestyle change to using the educator-patient relationship to empower the educator to serve as a patient navigator/case manager. The diabetic educator and the physician also work closely with a certified pedorthist. This provider’s knowledge and skill of health maintenance through the use of therapeutic footwear are important in the prevention and treatment of diabetic foot ulcers. Patients are taught to self-examine their feet, and this level of empowerment becomes important from a psychosocial perspective.
The primary surgeon is the “captain of the ship,” and it is his or her responsibility to coordinate the management and the function of the multidisciplinary team. It is important to identify the roles of the consultants such as the certified pedorthist (who will provide guidelines on therapeutic footwear and prefabricate a custom foot orthosis as needed), the vascular surgeon (who will be needed for patients with a nonhealing foot ulcer and a nonpalpable pedal pulse), the radiologist (who will be essential for suggesting imaging modalities for understanding the disease and its progression), the infectious disease specialist (who will guide duration of therapy and monitor associated antibiotic-induced organ-system morbidity), and the plastic surgeon (who may have unique requirements for wound care and developing relationships in clinical-care algorithms).
The multidisciplinary team approach involves the use of a consistent strategy throughout the hospital or health system. This is the first step in an attempt to decrease the negative impact on quality of life and resource consumption and is essential to diabetic foot care.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
“Smart” Implant Coating Delivers Antibiotics in Presence of Bacteria
Despite advances in sterile techniques and evidence-based use of perioperative antibiotics, periprosthetic joint infections still occur in 1% of primary and 3% to 7% of revision total joint arthroplasties. But a “smart” antimicrobial polymer coating, described in the July 20, 2016 Journal of Bone & Joint Surgery, has great potential to cut those percentages.
Stavrakis et al. devised a nontoxic, biodegradable polymer coating (called PEG-PPS for short) that locally delivers antibiotics (vancomycin and tigecycline in this study) both passively and actively, with the active release initiated by the presence of bacteria.
The authors tested the efficacy of the coating both in vitro and in vivo. In vitro, the release of antibiotics from the coating was enhanced in the presence of an oxidative environment, as would occur during a periprosthetic joint infection, demonstrating the coating’s “smartness.”
In vivo, using a mouse model of post-arthroplasty infection caused by Staphylococcus aureus, the authors showed radiographically that implants coated with PEG-PPS alone had a dramatic degree of periprosthetic osteolysis by postoperative day 7, compared with antibiotic-encapsulated PEG-PPS implants, which showed no detectable osteolysis. Similarly, the number of colony forming units of S. aureus cultured from implants on postoperative day 21 was significantly lower in the antibiotic-encapsulated implants than in the PEG-PPS-alone implants. (Interestingly, the tigecycline coating was more effective than the vancomycin coating in preventing bacterial colonization.)
While acknowledging that this proof-of-concept study needs to be replicated with other infectious organisms and in larger animals and humans, the authors conclude that PEG-PPS delivery of antibiotics has “great potential to minimize the incidence of postoperative infection following arthroplasty.”
JBJS Case Connections—Wrong-Way Wrist Bones
The ability of the small and complexly connected wrist bones to function properly supports everything from activities of daily living and work to the creation of art and music. This month’s “Case Connections” article explores wrist dislocations that required open reduction and some form of fixation. Considering the high degree of anatomical derangement and instability in these cases, the outcomes were remarkably good, thanks to carefully planned and executed orthopaedic interventions.
The springboard case, from the July 27, 2016 edition of JBJS Case Connector, describes the treatment of a 47-year-old male bicyclist who was hit by a car and sustained complete scaphoid and lunate dislocations. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 22-year-old man who sustained volar dislocation of the hamate and scapholunate dissociation as a result of a motor-vehicle accident
- a 30-year-old man who experienced volar dislocation of the lunate as well as of the proximal pole of a fractured scaphoid after falling from a height of 15 feet with his outstretched hand and wrist in extension
- a 25-year-old man who fell from a height of 20 feet and dislocated the hand and wrist dorsally about the scaphoid and lunate.
Anatomical reduction frequently required both dorsal and volar exposures. In one case, a successful outcome was achieved without addressing ligamentous injuries.
JBJS Editor’s Choice: The Harder They Fall
In the July 20, 2016 issue of The Journal, Louer et al. detail the association between distal radial fractures and poor balance. We have long understood that inherently poor balance was a major contributor to fall risk, and now we have more hard evidence thanks to this research team.
In this case-control evaluation comparing 23 patients ≥65 years of age who had sustained a low-energy distal radial fracture with 23 age- and sex-matched control patients, the authors found that those in the fracture cohort:
- Demonstrated poorer balance based on dynamic motion analysis (DMA) scores
- Were able to perform the balance test for significantly less time
- Rated themselves as having worse mobility
Among both cohorts, only 3 patients had completed an evaluation of or treatment for balance deficiencies.
The orthopaedic community has begun to pay attention to fragility fracture risk reduction through programs such as the AOA’s “Own the Bone” initiative, which focuses on identifying patients with fragility fracture and applying evidence-based treatment and prevention guidelines. Fragility fracture programs led by nurse practitioners or physician assistants have gained traction in many centers and have been proven effective in identifying at-risk patients and providing appropriate follow-up care.
Any intervention for patients presenting with the first fragility fracture must include assessing fall risk. Home evaluations addressing hazards such as loose carpets, poor lighting, and poorly designed stairway transitions are critical. We also know that activities such as tai chi, low-impact aerobics, and yoga, when regularly practiced, can help preserve balance. Now, developing programs that actually improve postural balance must be part of our collective research agenda as we attempt to address the major public health issue of fall-related fragility fractures.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS JOPA Image Quiz: Golf-Related Wrist Injury
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) highlights the case of a 34-year-old man who presented with a 1-month history of hand and wrist pain after driving his golf club into the ground during a swing. Anteroposterior (AP) and lateral radiographs of the wrist are shown, and findings from the physical exam are described.
The Image Quiz reviews the anatomy of the wrist, focusing on the symptoms and mechanisms of hamate injuries. The quiz question is: After standard AP and lateral radiographs, which imaging modality or view would be most helpful in arriving at a definitive diagnosis? Options for treating a fracture of the hook of the hamate are also discussed.
ACL Surgery Trends, 2007 to 2014
In a population-based epidemiological study published in the July 6, 2016 Journal of Bone & Joint Surgery, Tibor et al. found that from 2007 to 2014:
- Many ACL-reconstruction surgeons changed from a transtibial approach to either an anteromedial portal or lateral approach for femoral-tunnel drilling.
- Most did not substantially change the types of grafts they used.
- Many eschewed first-generation bioabsorbable implants in favor of biocomposite fixation devices.
The authors found no change in cumulative revision rates during the study period.
Tibor et al. analyzed information from 21,686 primary ACL reconstructions housed in a Kaiser Permanente registry that collected data from surgeries performed in 33 hospitals by 246 surgeons in urban, rural, and suburban settings in three Western US states. This wide-ranging data set, the authors say, “increases the generalizability of our findings to other community-based surgeons.”
The authors admit, however, that the epidemiological nature of the study “offers only limited insight into associated outcomes,” and they were unable to analyze cost trends because the registry does not capture cost data.
What’s New in Spine Surgery
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, OrthoBuzz asked Theodore Choma, MD and Darrel Brodke, MD, co-authors of the June 15, 2016 Specialty Update on spine surgery, to select the five most clinically compelling findings from among the more than 40 studies they cited.
Antifibrinolytics
–A Level-I meta-analysis of 11 RCTs showed that tranexamic acid significantly lowered perioperative blood loss and transfusion requirements during spine surgery, with no associated increased incidence of heart attack or pulmonary embolism.1
Adult Spinal Deformity
–An analysis of prospective registry data from 766 adult patients with spinal deformity found that health-related quality-of-life scores for those patients prior to any intervention were lower than pre-intervention scores for patients with arthritis, chronic lung disease, diabetes, and congestive heart failure. The authors concluded that the global burden of spinal deformity warrants research and health-policy attention comparable to that given to other high-burden conditions.2
Lumbar Spine
–A double-blind RCT of patients presenting to the emergency department with acute nonradicular low back pain found no difference in one-week disability scores among three groups: those given naproxen + cyclobenzaprine; those given naproxen + oxycodone/acetaminophen; and those given naproxen + placebo. The findings led the authors to conclude that adding those drugs to naproxen provides no clinical benefit.3
–A post-hoc analysis of SPORT data focused on patients ≥80 years old with degenerative spondylolisthesis found that operative treatment conferred a significant benefit relative to nonoperative treatment. The researchers found no significant increases in postoperative complication or mortality rates in this patient population compared with younger post-op patients.
Spine Fractures
–A 16- to 22-year follow-up of a previous randomized trial of 47 patients from the 1990s who had been randomized to operative or nonoperative treatment after a stable thoracolumbar burst fractures found that those treated nonoperatively had less pain and better function than those who had been treated operatively.
References
- Cheriyan T,Maier SP 2nd., Bianco K, Slobodyanyuk K, Rattenni RN, Lafage V, Schwab FJ, Lonner BS, Errico TJ. Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. Spine J. 2015Apr 1;15(4):752-61. Epub 2015 Jan 21.
- Pellisé F, Vila-Casademunt A, Ferrer M, Domingo-Sàbat M, Bagó J, Pérez Grueso FJ, Alanay A, MannionAF, Acaroglu E;European Spine Study Group, ESSG. Impact on health related quality of life of adult spinal deformity (ASD) compared with other chronic conditions. Eur Spine J. 2015 Jan;24(1):3-11. Epub 2014 Sep 14.
- Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015 Oct 20;314(15):1572-80.
JBJS Classics: Blount Disease by Another Name
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 about these classics by clicking on the “Leave a Comment” button in the box to the left.
When Walter Putnam Blount, MD described “Tibia Vara: Osteochondrosis Deformans Tibiae” in the January 1937 issue of The Journal of Bone & Joint Surgery, he probably did not realize that this mouthful of a term would become known simply as “Blount disease.” With a keen interest in children’s limb and spinal deformities, Blount was a pioneer pediatric deformity surgeon. He spent most of his career at the Children’s Hospital in Milwaukee and was clearly ahead of his time.
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Additionally, he parsed out 16 other cases of genu varum that previous authors had reported as being secondary to rickets, infection, or other etiologies. In vivid detail, including tracings of these other patients’ radiographs, Blount corroborated that this newly described entity was indeed something different. He supplemented his research with histologic specimens from the affected growth plate and surrounding unossified cartilage of the proximal tibia.
Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Although most of his Caucasian patients in the 1937 study were not overweight, with the changing U.S. demographics and the prevalence of childhood obesity, his suggestion of a genetic and a mechanical basis for this growth-plate disorder remains plausible.
Based on the age of onset of the deformity, Blount recognized that there were two distinct forms of tibia vara, which he classified as infantile and adolescent. While the radiographs in the article only show the frontal images, he clearly documented the associated axial plane deformities with internal tibial torsion and ipsilateral shortening. Though Blount was a big proponent of the Milwaukee brace for managing spinal deformities in children, he seemed disenchanted with using orthoses to treat tibia vara. He instead advocated surgical correction via a valgus realignment proximal tibial osteotomy, a recommendation that remains relevant to this day.
Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” as another way of treating pediatric limb deformities. Interestingly, more than a decade after his description of tibia vara, Blount published another masterpiece in JBJS, “Control of Bone Growth by Epiphyseal Stapling.” Prior to this time, (hemi)epiphyseodesis was largely performed by the Phemister technique, with permanent ablation of the growth plate. By recognizing that physeal growth can be harnessed to correct angular deformities by inserting removable implants such as staples across the growth plate, Walter Blount, through these two classic JBJS articles and various other contributions, outlined essentially all viable options that are currently available to treat this disorder that fittingly bears his name.
In his presidential address to the American Academy of Orthopedic Surgeons in January 1956, Blount noted, “I should rather be remembered as a thoughtful surgeon than as a bold one.” His wish has indeed come true.
Sanjeev Sabharwal, MD, MPH
JBJS Deputy Editor
No BMP–Cancer Link Found in Older Patients After Lumbar Arthrodesis
The July 6, 2016, edition of The Journal of Bone & Joint Surgery features a large case-cohort study that may help older patients and clinicians decide whether to use bone morphogenetic protein (BMP) as an adjunct to lumbar arthrodesis. Among Medicare patients aged 65 years and older, Beachler et al. found that BMP use was not associated with the following:
- Overall cancer risk
- Increased risk of individual cancer types
- Increased risk of cancer in people who had cancer prior to undergoing lumbar arthrodesis
- Increased mortality after a cancer diagnosis
BMP was used in 30.7% of >3,600 lumbar-arthrodesis patients analyzed, and the lack of association between BMP use and cancer held whether patients received the growth factor as part of an FDA-approved anterior lumbar interbody fusion or as an off-label application.
In an accompanying commentary, Singh et al. laud the authors for designing a study that was not only well-powered but also analyzed risk among those with a medical history of cancer. The commentators emphasize, however, that the median follow-up in this study was 2.4 years, leading them to wonder “whether this time frame is sufficient to evaluate the impact of BMPs on carcinogenesis.”
Until a large, prospective, randomized trial on this subject is conducted, Singh et al. say, “the decision to use BMPs should be made on the basis of sound clinical judgment by the treating physician after a full disclosure of the potential risks to the patient.”
Literature Update: Options for Treating Ankle Arthritis
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher E. Gross, MD, in response to the May 18, 2016 JBJS Specialty Update on Foot and Ankle Surgery.
Ankle arthritis occurs along a spectrum of severity—ranging from minor cartilage lesions to significant degenerative disease.
To preserve ankle function and to prevent possible evolution into arthritic changes, osteochondral lesions should be treated as soon as they become symptomatic. In one prospective cohort study summarized by Lin and Yeranosian in the May 18, 2016 JBJS Specialty Update, thirty patients with talar osteochondral lesions underwent arthroscopic implantation of bone marrow-derived cells onto a collagen scaffold. Patients who received adjunctive biophysical stimulation by pulsed electromagnetic fields (PEMFs) had higher AOFAS scores at one year post-operatively than those who did not.1 The proposed explanation for this outcome is that PEMFs decrease inflammatory cytokines and help differentiate stem cells into chondrocytes.
Total ankle replacements (TARs) have become a viable surgical option for patients with end-stage ankle arthritis. In a study comparing patients undergoing TAR with those undergoing arthrodesis,2 TAR patients had higher expectations of their surgery than fusion patients and were more likely to have higher satisfaction scores post-operatively. In a functional comparison of TAR and arthrodesis, Jastifer, et al. found that patients who received a TAR had an easier time walking uphill and down/upstairs.3 In another study evaluating functional biomechanics following TAR surgery, groups whose procedure included Achilles tendon lengthening were compared to those who had TAR alone.4 There were no between-group differences in functional outcomes or gait mechanics.
In a study comparing results and complications of TAR in patients with rheumatoid arthritis to patients who had ankle replacements due to either traumatic or primary arthritis, the authors found similar functional outcomes and complication rates.
Despite these many examples of TAR success in the recent literature, the procedure is not without its shortcomings. Rahm, et al.5 compared patients who underwent primary ankle fusion to those who underwent salvage ankle arthrodesis because of a failed TAR. Those who had a salvage procedure had more pain and decreased functionality compared to those who underwent a primary fusion.
Christopher E. Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston.
References
- Cadossi M, Buda RE, Ramponi L, Sambri A, Natali S, Giannini S. Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study. Foot Ankle Int. 2014 Oct;35(10):981-7.
- Younger AS, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, et al. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int. 2015 Feb;36(2):123-34.
- Jastifer J, Coughlin MJ, Hirose C. Performance of total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int. 2015 Jan;36(1):11-7.
- Queen RM, Grier AJ, Butler RJ, Nunley JA, Easley ME, Adams SB, Jr., et al. The influence of concomitant triceps surae lengthening at the time of total ankle arthroplasty on postoperative outcomes. Foot Ankle Int. 2014 Sep;35(9):863-70.
- Rahm S, Klammer G, Benninger E, Gerber F, Farshad M, Espinosa N. Inferior results of salvage arthrodesis after failed ankle replacement compared to primary arthrodesis. Foot Ankle Int. 2015 Apr;36(4):349-59.
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