Spring and Summer 2017 are busy seasons for Own the Bone, the American Orthopaedic Association’s national post-fracture, systems-based, multidisciplinary fragility fracture prevention initiative:
On Thursday, May 4, at 5:00pm CDT (6:00pm EDT) Paul A. Anderson, MD, FAOA, from the University of Wisconsin, and Karen Cummings, PA-C, from the University of Michigan, will discuss the components of a successful secondary fracture prevention program.
Join the National Association of Orthopaedic Nurses (NAON) and The American Orthopaedic Association for this full-day event on Friday, June 23. Attendees will receive a Fragility Fracture Symposium Certificate of Completion and continuing education credit.
Join Physician Assistants in Orthopaedic Surgery (PAOS) and Own the Bone for a full-day fragility fracture and bone health workshop on the first day of the PAOS Annual Conference, Monday, August 21, in Baltimore.
An estimated 40% of total costs from a total hip arthroplasty (THA) episode are accrued from post-discharge services. With that in mind, Austin et al. embarked on a randomized controlled trial comparing outcomes among two groups of primary THA patients: those who followed a 10-week self-directed home exercise regimen (n=54) and those who received a combination of in-home and outpatient physical therapy (PT) for 10 weeks (n=54). The results were published in the April 19, 2017 edition of The Journal of Bone & Joint Surgery.
At 1 month and 6 to 12 months after surgery, patients in both groups showed significant preoperative-to-postoperative improvements in function as measured by all administered instruments (Harris Hip Score, WOMAC Index, and SF-36 Physical Health Survey). However, there was no difference in any of the measured functional outcomes between the two groups.
In addition, a total of 30 patients (28%) crossed over between groups: 20 (37%) from the formal physical therapy group and 10 (19%) from the home exercise group. The 10 patients who crossed over from home exercise to formal PT were not meeting progress goals; they tended to be older and had worse preoperative function than those in that cohort who did not cross over.
So, while this study provides evidence that unsupervised home exercise can be as effective as a structured rehabilitation program for most patients, the authors say the following patient characteristics might be indications for a referral to formal PT:
- Older age
- Poorer preoperative function
- Severe preoperative gait imbalance
- Postoperative neurological complications
- Expectations for quick return to high-level activity
The prevalence of rotator-cuff tears is reported to be as high as 30% in people over the age of 60 years. Yet there is still no clear consensus on the indications for surgical treatment of these tears.
On Wednesday, May 24, 2017 at 7:00 PM EDT, The Journal of Bone & Joint Surgery (JBJS) and the Journal of Shoulder and Elbow Surgery (JSES) will host a complimentary* webinar that presents findings from two recently published Level I studies of rotator-cuff tears.
- John Kuhn, MD, discusses findings from a prospective multicenter cohort study in JSES that identifies the characteristics with the greatest influence over whether patients choose surgery for a chronic, symptomatic, full-thickness rotator cuff tear.
- Stefan Moosmayer, MD, reports results from a randomized controlled trial in JBJS that found interesting clinical-outcome differences between physiotherapy alone and tendon repair in patients with tears ≤3 cm.
This webinar is co-moderated by Andrew Green, MD, JBJS deputy editor and chief of the Division of Shoulder and Elbow Surgery at the Warren Alpert Medical School of Brown University and Bill Mallon, MD, past-president of the American Shoulder and Elbow Surgeons (ASES) and editor-in-chief of the Journal of Shoulder and Elbow Surgery (JSES). The webinar will offer additional perspectives on the authors’ presentations from two rotator-cuff experts—Lawrence Higgins, MD and Leesa Galatz, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.
Seats are limited, so register now!
*This webinar is complimentary for those who attend the event live.
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 Sheldon Lin, MD, co-author of the April 19, 2017 Specialty Update on foot and ankle surgery, to select the five most clinically compelling findings from among the more than 50 studies cited in the article.
–Recommendations for venous thromboembolism (VTE) prophylaxis in isolated foot and ankle fractures are conflicting. In a prospective study, Zheng et al.1 determined the incidence of VTE in 814 patients who received either low-molecular-weight heparin or placebo for 2 weeks postoperatively. The overall incidence of deep vein thrombosis was 0.98% in the heparin group and 2.01% in the placebo group, with no significant difference between the two. The risk factors were high body mass index (BMI) and advanced age. The authors concluded that routine chemical prophylaxis was not necessary in cases of isolated foot and ankle fractures.
Age and Total Ankle Arthroplasty
–Concerns regarding implant survivorship in younger patients have prompted investigations into the effect of age on total ankle arthroplasty outcomes. Demetracopoulos et al.2 prospectively compared patient-reported outcomes and revision rates in patients who were 70 years of age. At the 3.5-year follow-up, patients who were 70 years of age, although no differences were observed in pain, need for reoperation, or revision rates between groups.
Hallux Rigidus/Hallux Valgus
–Joint-preserving arthroplasties for hallux rigidus have been proposed as an alternative to first metatarsophalangeal joint arthrodesis. However, they have shown high rates of failure with associated bone loss, rendering salvage arthrodesis a more complicated procedure with worse outcomes. A Level-I study by Baumhauer et al.3 investigated the use of a synthetic cartilage implant that requires less bone resection than a traditional arthroplasty. Patients were randomized to implant and arthrodesis groups. At the 2-year follow-up, pain level, functional scores, and rates of revision surgical procedures were statistically equivalent in both groups. Secondary arthrodesis was required in <10% of the implant group and was considered to be a straightforward procedure because of preservation of bone stock.
–Hallux valgus surgical procedures are commonly performed under spinal, epidural, or regional anesthesia. Although peripheral nerve blocks have become increasingly popular with the advent of ultrasound, the associated learning curve has limited more widespread use. A Level-I study by Karaarslan et al.4 compared the efficacy of ultrasound-guided popliteal sciatic nerve blocks with spinal anesthesia in patients undergoing hallux valgus correction. The popliteal block group demonstrated decreased pain scores at every time point up to 12 hours postoperatively, longer time to first analgesic requirement, and increased patient satisfaction scores compared with the spinal anesthesia group. The popliteal block group also did not experience the adverse effects of hypotension, bradycardia, and urinary retention occasionally seen with spinal anesthesia.
–Orthobiologics continue to generate considerable interest within the orthopaedic community. Platelet-rich plasma and hyaluronic acid have been investigated as adjuncts to promote healing. In a Level-I study, Görmeli et al.5 randomized patients to receive platelet-rich plasma, hyaluronic acid, or saline solution injections following arthroscopic debridement and microfracture of talar osteochondral lesions. At the intermediate-term follow-up, the platelet-rich plasma and hyaluronic acid groups exhibited a significant increase in AOFAS scores and decrease in pain scores compared with the control group, with the platelet-rich plasma group showing the greatest improvement.
- Zheng X, Li DY, Wangyang Y, Zhang XC, Guo KJ, Zhao FC, Pang Y, Chen YX. Effect of chemical thromboprophylaxis on the rate of venous thromboembolism after treatment of foot and ankle fractures. Foot Ankle Int. 2016 Nov;37(11):1218-24.
- Demetracopoulos CA, Adams SB Jr, Queen RM, DeOrio JK, Nunley JA 2nd, Easley ME. Effect of age on outcomes in total ankle arthroplasty. Foot Ankle Int. 2015 Aug;36(8):871-80.
- Baumhauer JF, Singh D, Glazebrook M, Blundell C, De Vries G, Le ILD Nielsen D, Pedersen ME, Sakellariou A, Solan M, Wansbrough G, Younger AS, Daniels T; for and on behalf of the CARTIVA Motion Study Group. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot Ankle Int. 2016 May;37(5):457-69.
- Karaarslan S, Tekg¨ul ZT, S¸ ims¸ek E, Turan M, Karaman Y, Kaya A, Gönüllü M. Comparison between ultrasonography-guided popliteal sciatic nerve block and spinal anesthesia for hallux valgus repair. Foot Ankle Int. 2016 Jan;37(1):85-9. Epub 2015 Aug 20.
- Görmeli G, Karakaplan M, Görmeli CA, Sarıkaya B, Elmalı N, Ersoy Y. Clinical effects of platelet-rich plasma and hyaluronic acid as an additional therapy for talar osteochondral lesions treated with microfracture surgery: a prospective randomized clinical trial. Foot Ankle Int. 2015 Aug;36(8):891-900.
From the perspective of a geriatric patient with a hip fracture, having a preoperative echocardiogram may not seem like a big deal, especially since it’s a noninvasive test. However, as Adair et al. reveal in an April 19, 2017 JBJS study, following clinical guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA) could have prevented “cardiac echoes” from being done in 34% of 100 elderly hip fracture patients without missing any disease. Such unnecessary testing not only adds cost to the health care system, but can also delay surgical treatment for an operation that evidence suggests is best performed within 24 to 48 hours.
A single reviewer blinded to the later results of the tests assessed whether the ACC/AHA guidelines were followed in each case of an ordered echo; when ≥1 of the criteria were met, the echo was considered ordered in accordance with the guidelines. The rate of adherence to the guidelines was 66% over the 3.5-year study period. No important heart disease was found in any of the 34 patients who underwent an echocardiogram that had not been indicated by the guideline criteria, and 14 of the 66 patients (21%) for whom an echo was indicated by the criteria were found to have heart conditions serious enough to modify anesthesia or medical management.
The most common documented reasons for ordering an echo outside the guideline criteria were dementia that prevented evaluation of preoperative cardiac condition and generic “evaluation of cardiac function,” even though those patients had no history, physical exam findings, or work-ups that suggested heart disease.
Adair et al. conclude that these findings “suggest that integration of [clinical practice guidelines] into a perioperative protocol has the potential to improve the efficiency of preoperative evaluation, reduce resource utilization, and reduce the time to surgery without sacrificing patient safety.”
In the April 19, 2017 issue of The Journal, Cancienne et al. compare complication and readmission rates for patients undergoing ambulatory shoulder arthroplasty with those among patients admitted as hospital inpatients postoperatively. Because the analysis was based on data from a large national insurer, we can be quite sure of appropriate coding and accurate data capture.
Similar to our recent report regarding outpatient hand and elbow surgery, in no instance were complications present at a significantly higher rate in the patients who underwent ambulatory shoulder arthroplasty, and the rate of hospital readmission after discharge was not significantly different at 30 or 90 days between the two cohorts.
This definitely is a tip of the hat to orthopaedic surgeons, nurses, and anesthesiologists, who are making sound decisions regarding which patients are appropriate for outpatient arthroplasty. Cancienne et al. found that obesity and morbid obesity were significant demographic risk factors for readmission among the ambulatory cohort, and they also identified the following comorbidities as readmission risk factors in that group:
- Peripheral vascular disease
- Congestive heart failure
- Chronic lung disease
- Chronic anemia
These results offer further documentation regarding the shift away from hospital-based care after orthopaedic surgery. Those of us who perform surgery in dedicated orthopaedic centers as well as general hospital operating rooms understand the concepts of efficiency, focus, maintenance of team skills, and limiting waste. Those objectives in large part drive the move to outpatient surgery. But patients, who almost always prefer to be at home and sleep in their own beds (or recliners in the case of shoulder replacement), may be an even more powerful driver of ambulatory care in the future.
Major advances in postoperative pain management are great enablers in this regard, and I believe the trend will continue. I envision a day when the only patients admitted to hospitals after orthopaedic surgery are those with unstable medical issues who potentially may need ICU care postoperatively.
Marc Swiontkowski, MD
Anecdotally, many patients experience extreme discomfort after shoulder surgery. The April 5, 2017 issue of JBJS features results from a randomized controlled trial comparing morphine consumption and pain during the 24 hours following shoulder arthroplasty among two groups. One group (n=78) received a preoperative interscalene brachial plexus blockade, while the other (n=78) received intraoperative infiltration of bupivacaine liposome suspension.
Mean total postoperative narcotic consumption during the 24 hours after surgery was not significantly different between the two groups, although intraoperative narcotic consumption was significantly lower in the blockade group. The mean VAS pain scores were significantly lower in the blockade group at 0 and 8 hours postoperatively, the same as in the infiltration group at 16 hours postoperatively, and significantly higher than those in the infiltration group at 24 hours postoperatively. That last finding in patients undergoing blockade represents the phenomenon known as “rebound pain.”
The authors, Namdari et al., conclude that the “optimal postoperative pain regimen for shoulder arthroplasty…require[s] further investigation.” But their analysis uncovered four demographic factors that were associated with higher pain scores at 24 hours after surgery, regardless of the analgesic technique used:
- Younger age
- History of depression
- Higher Charlson Comorbidity Score
- Higher preoperative VAS score
In his commentary on the study, Ranjan Gupta, MD notes that one downside of the block approach is “an inability to assess the patient’s neurologic function after the surgical procedure.” His own early clinical experience leads him to favor the admittedly “laborious” infiltration approach, partly because “both patients and orthopaedic nurses who take care of these patients in the immediate postoperative time period can readily appreciate the lack of rebound pain.”
In the April 5, 2017 issue of The Journal, Noureldin et al. analyzed more than 14,000 procedures from the NSQIP database to determine the rate of unplanned 30-day readmission after outpatient surgical procedures of the hand and elbow. The 1.2% rate seems well within the range of acceptability, particularly because the more than 450 institutions contributing to this database probably serve populations who don’t have the best overall health and comorbidity profiles.
Missing causes for about one-third of the readmissions illustrate one issue with data accuracy in these large administrative datasets. While the authors acknowledged a “lack of granularity” as the greatest limitation in analyzing large databases, they added that the readmissions with no listed cause “were likely unrelated to the principal procedure.”
It was not surprising that infection was the most common cause for readmission. However, it would have been nice to know the rate of confirmed infection via positive cultures, as I suspect many of these patients were readmitted for erythema, swelling, warmth, and discomfort associated with postoperative hematoma rather than infection.
Regardless of the need for higher-quality data on complications following outpatient orthopaedic surgical procedures, this analysis gives us more confidence that the move toward outpatient surgical care in our specialty is warranted. I think most patients would rather sleep in their own home as long as preoperative comorbidities and ASA levels are considered and adequate postoperative pain control can be achieved in an outpatient setting. The trend toward outpatient orthopaedic treatment is likely to continue as we gather higher-quality data and better understand the risk-benefit profile.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from E. Scott Paxton, MD, in response to a recent “Rapid Recommendation” in The BMJ.
An international panel convened by The BMJ recently issued a “Rapid Recommendation” that strongly recommends against using low-intensity pulsed ultrasound (LIPUS) in patients with fracture or osteotomy because the treatment doesn’t improve functional recovery or pain.1
The systematic review on which the recommendation was based reviewed 26 trials of nearly 1600 patients with fracture or osteotomy who were randomized to either LIPUS or sham/no device.2 The authors concluded with moderate to high levels of certainty that the treatment had little effect on the time patients could return to work, time to full weight-bearing activity, pain levels, future operations, or time to radiographic healing.
In 2009, Busse et al. performed a similar meta-analysis, concluding that “evidence for the effect of low intensity pulsed ultrasonography on healing of fractures is moderate to very low in quality and provides conflicting results.”3 This analysis only included 13 trials, however. Then, in 2016, Busse et al. published results from the TRUST study,4 a blinded, randomized controlled trial of 501 patients from 43 North American academic trauma centers who had a fresh tibial shaft fracture treated with intramedullary nailing. The authors based their sample size calculations on the minimal clinically important difference on the SF-36 PCS, as this was a co-primary outcome. The authors found no improvement in radiographic healing time or functional recovery with the use of LIPUS. However, the authors noted that only 1 nonunion occurred among 195 sham-treated patients, demonstrating that this group was at extremely low risk for nonunion at baseline.
Including the TRUST trial in the 2017 meta-analysis of LIPUS led Schandelmaier et al. to the aforementioned conclusions and informed the strong BMJ Rapid Recommendation against the use of LIPUS for patients with any bone fracture or osteotomy. However, this recommendation was based in large part on the TRUST trial, which was unable to directly assess the effectiveness of LIPUS on reducing nonunion rates because of the almost universal healing of the fractures studied.
The BMJ Rapid Recommendation states “there was high quality evidence showing a lack of benefit in accelerating healing for fresh fractures; thus it is unlikely that LIPUS would improve outcomes in patients with non-union.” However, the effect of LIPUS on preventing nonunions in fractures known to have high nonunion rates or on treating established nonunions will require further high-quality studies looking at those patients specifically.
Scott Paxton, MD is an assistant professor in the Department of Orthopaedic Surgery at the Warren Alpert Medical School at Brown University and a fellowship-trained shoulder and elbow surgeon at University Orthopedics in Providence, Rhode Island.
- Poolman RW, Agoritsas T, Siemieniuk RAC, et al. Low intensity pulsed ultrasound (LIPUS) for bone healing: a clinical practice guideline. BMJ. February 2017:j576-j576. doi:10.1136/bmj.j576.
- Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ. 2017;356:j656. doi:10.1136/bmj.j656.
- Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ. 2009;338:b351. doi:10.1136/bmj.b351.
- TRUST Investigators writing group, Busse JW, Bhandari M, et al. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016;355:i5351. doi:10.1136/bmj.i5351.
In 2015, JBJS launched an“article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of April 2017, JBJS and OrthoBuzz readers will have access to the JOSPT article titled “Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial.”
In that randomized clinical trial of 43 patients (50 hips), dry needling was found to be a non-inferior treatment alternative to cortisone injections.