The November 2, 2016 issue of JBJS contains the second 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 physicians.
The second “What’s Important” piece comes from Dr. Augusto Sarmiento of the University of Miami School of Medicine. In his essay titled “Putting Patients First,” Dr. Sarmiento emphasizes that quality patient care must always outweigh orthopaedist self-interest.
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.
Ulnar shortening osteotomy is a widely accepted procedure for surgical treatment of ulnar impaction syndrome, but many techniques require special instrumentation to achieve accurate shortening, adequate fixation, and sufficient rotational control. In the November 2, 2016 issue of The Journal of Bone & Joint Surgery, Papatheodorou et al. report on outcomes in 164 patients who underwent so-called “step-cut” osteotomies for positive ulnar variances that ranged from +1 to +6 mm.
The technique itself, which utilizes a standard neutralization plate and lag screw for fixation, is summarized and illustrated in the article. The authors emphasize that the step-cut approach does not require special jigs or instrumentation.
Patients were followed for a median of 66 months. The overall union rate was 98.8%; postoperative ulnar variance ranged from –1 to +1.5 mm after a mean overall ulnar shortening of 2.5 mm. All patients had significant postoperative improvements in pain, range of motion, grip strength, and Mayo Modified Wrist Score. Plate removal due to irritation was necessary in only 12 (7.3%) of the patients.
The authors also found in these patients “a lower rate of degenerative changes at the distal radioulnar joint compared with rates reported in previous studies.” They attribute this to the relatively small amount of ulnar shortening with the step-cut procedure, which they surmise “diminishes the rate of articular incongruity and hence arthritis of the distal radioulnar joint.” On the cost side of the matter, the authors noted that at their institution, special ulnar osteotomy systems cost almost 10 times more than a standard neutralization plate.
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent JAMA study, the following two commentaries come from Chad Krueger, MD, and Shahriar Rahman, MS.
“Hmmm…. Maybe I’m operating on too many ankle fractures.” That was my first thought as I read the abstract of the recent Willett et al. study in JAMA. They conducted a well-designed, randomized controlled trial that compared operative and nonoperative treatment of unstable ankle fractures, using the Olerud-Molander Ankle Score at 6 months postoperatively as the primary outcome measure.
On the surface, it appeared as though patients who were treated nonoperatively with close contact casting did just as well as those who underwent operative intervention. This seemed to be not only the case with the primary outcome measure, but also with secondary outcomes such as quality of life, pain, and patient satisfaction. “Do less” appeared to be the main message of the abstract. However, I became more skeptical after critically reading the entire article.
First off, the study was designed to determine differences between treatment groups, not to prove that they were equivalent. Finding no difference is not the same as showing equivalence, and the article did the former, not the latter.
There are also a few things about the study that may limit the wide applicability of the findings and provide some solace to surgeons like me who feel that fixing unstable ankle fractures provides superior outcomes. First, only initial radiographs were used to determine who had unstable ankle fractures. Stress radiographs were an exclusion criterion, so for the many ankle fractures that require such imaging to determine instability, the results from Willett et al. may not apply.
Second, the study was designed to compare these treatments in older adults. The mean ages of operative and nonoperative groups were 69.8 and 71.4 years old, respectively, and almost 75% of both groups were female. While bone density was not measured in either group, it is likely that many patients included in this study had osteoporotic disease, which introduces another potential variable when interpreting the findings.
Furthermore, nearly 20 percent of all patients who initially were treated with casting developed some type of complication that required conversion to surgical fixation. This finding, plus the fact that all casts were applied by surgeons in the operating room with patients under general or spinal anesthesia, suggests that treating unstable ankle fractures with surgical fixation in a single visit would perhaps provide the most definitive treatment.
So, I will probably continue to offer patients with unstable ankle fractures surgical fixation. I have never tried the close contact casting that was described in the article, and I suspect, despite the authors’ claim of evidence to the contrary, that there is a significant learning curve associated with that technique. If about one out of every five patients I perform casting on as definitive treatment ends up needing additional procedures, I am not sure I have done the patient justice. While this study provides interesting evidence and may apply to a small subset of my older patients, I think it has limited applicability in other patients who present with unstable ankle fractures.
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.
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The Willett et al. study in JAMA indicates that some patients older than 60 years with unstable ankle fractures can be treated by modified casting alone, without the need for operative stabilization and fixation. The study protocol allowed conversion to surgery among patients randomized to casting if reduction was not possible during the initial procedure or was lost within the first 3 weeks.
One hundred surgeons applied close contact casting at 24 major trauma centers and general hospitals in the UK. After 6 months, the mean Olerud-Molander Ankle Score was 66.0 in the surgery group vs 64.5 in the casting group—no significant difference in the primary outcome.
Secondary outcomes showed that the rate of radiographic malunion was 15% in the casting group compared with 3% in the surgery group. Conversion from casting to operative treatment was high: of the 311 patients randomized to casting, 70 (23%) were ultimately treated by internal fixation, including 18 never treated with close contact casting and 52 who lost reduction and required conversion to internal fixation. Rates of infection and wound complications were 10% in the surgical group versus 1% in the casting group. Additional operating room procedures were required in 6% of the surgery group and 1% of the casting group. Casting required less operating room time compared with surgery.
The overall similarity in clinical outcomes in this study challenges the importance of restoring exact ankle-joint congruence in older adults and suggests that function and pain are not as closely related to malunion as many clinicians believe. Neither method yielded an entirely satisfactory outcome in older adults. In older patients with lower demand, shorter life expectancy, lesser bone and tissue quality, and diminished capacity for healing, the rates of delayed or infected wound healing and loss of implant fixation are greater.
Casting may be an imperfect alternative to surgery particularly in developing countries. One must remember, however, that plaster technique is an art. Achieving the successful outcomes with close contact casting as described by Willett et al. is likely to pose a learning curve. Further studies are needed to identify which specific patients are most and least likely to benefit from casting.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh.
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 November 2016:
- Comparative Survivorship of Different Tibial Designs in Primary Total Knee Arthroplasty
- All-Polyethylene Versus Metal-Backed Tibial Components
- Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty
- Risk of Total Knee Arthroplasty After Operatively Treated Tibial Plateau Fracture
- Long-Term Clinical Outcomes and Survivorship of Press-Fit Condylar Sigma Fixed-Bearing and Mobile-Bearing Total Knee Prostheses in the Same Patients
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.
The evolution of more rational educational programs and other societal changes point to a future where an increasing number of orthopaedic surgeons will be female. Thankfully, we have made gains in adjusting the medical community’s perspective on careers in orthopaedic surgery. No longer are we perceived to be “stronger than a mule and twice as smart” or merely “buckles and braces men.” Evolving interventional techniques that rarely require brute force have also helped change this view.
At the same time, with the rapidly increasing need for musculoskeletal care as the population ages, we need every orthopaedic practitioner—male and female—to remain as healthy and active as possible. Epidemiologic studies of surgeon health have revealed real concerns for neck and back degenerative changes and cancer risk.
In the November 2, 2016 edition of The Journal, Valone et al. tackle the issue of exposure of the female breast to intraoperative radiation. In a nifty study incorporating C-arm fluoroscopy and an anthropomorphic torso phantom equipped with breast attachments and dosimeters, the authors found that:
- The median dose-equivalent rate of scatter radiation to the breast’s upper outer quadrant (UOQ) was higher than that to the lower inner quadrant.
- C-arm cross-table lateral projection was associated with higher breast radiation exposure than anteroposterior projection.
- Size, fit, and breast coverage of lead protection matter.
The findings should prompt redesign of protective aprons and vests to more effectively cover the breast and axilla. We could also use more well-designed longitudinal studies to identify the risk factors for neck, back, and shoulder injury as well as gain a better understanding of the real risk of surgeon exposure to intraoperative radiation.
Annual occupational radiation dose limits to the breast have not yet been established. But in the meantime, Valone et al. recommend distancing the axilla from the C-arm and placing the X-ray source beneath the operating table or on the contralateral side to reduce radiation exposure to the UOQ of the breast.
Marc Swiontkowski, MD
Despite the remarkable success of modern treatments for congenital clubfoot, including the Ponseti method, some kids still end up with a rigid residual deformity after walking age. In the October 19. 2016 edition of JBJS, Dragoni et al. investigated the Ponseti treatment in 44 patients (68 feet; mean age of 4.8 years) who had been previously treated with various surgical and conservative protocols but whose outcomes were fair or poor, according to International Clubfoot Study Group scores.
The authors performed Ponseti manipulation and cast application with the patients under conscious sedation. Depending on the clinical situation, some patients also received percutaneous heel-cord surgery or percutaneous fasciotomy, and all those over 3 years old (88% of the feet) received tibialis anterior tendon transfer (TATT).
At a mean follow-up of just under 5 years, 84% of the feet had achieved excellent or good results. No feet showed a lack of plantar flexion or were not plantigrade. Despite the mobility problems that a series of long leg Ponseti casts posed for kids of walking age, the authors reported that “families enthusiastically agreed to continue the Ponseti treatment as soon as they looked at the improved shape of their child’s foot after removal of the first plaster cast.”