More Clinical Data on the “Clavicle Question”
The last time OrthoBuzz reported on a JBJS randomized trial looking at treatment of midshaft clavicle fractures, the authors concluded that “neither treatment option [nonoperative or surgical] is clearly superior for all patients” and that “the clavicular fracture is preeminently suitable for shared treatment decision-making.”
Now, a multicenter randomized trial by Ahrens et al. published in the August 16, 2017 JBJS adds more data for that shared decision-making discussion. In this trial, 300 patients with a displaced midshaft clavicle fracture were randomized to receive either open reduction and internal fixation (ORIF) with a plate or nonoperative management. Patients were recruited from a range of UK hospitals, and a single implant and standardized technique were used in the operative group. The rehabilitation protocol was the same for both groups.
The union rate in both groups at 3 months was low, approximately 70%. But at 9 months after the injury, the nonunion rate was <1% in the surgically treated patients, compared to 11% in the nonsurgically treated patients. The patient-reported scores (DASH and Constant-Murley) were significantly better in the operative group at 6 weeks and 3 months, but were equivalent to those in the nonoperative group at 9 months.
“Overall,” the authors conclude, “we think that surgical treatment for a displaced midshaft clavicle fracture should be offered to patients, and [these findings] can provide clear, robust data to help patients make their choices.”
JBJS/JOSPT Webinar–Treating Ankle Sprains and Instability
Ankle sprain is a common musculoskeletal injury throughout the world, affecting tens of thousands of patients daily. What treatments for lateral inversion ankle injury are most effective? When is a wait-and-see approach more beneficial than a training program, and functional interventions more appropriate than surgical treatment? What surgical interventions yield better outcomes for function and instability compared with conservative treatment, particularly when the calcaneofibular ligament is disrupted, and does one postoperative regimen produce better results than another?
On Tuesday, September 19, 2017 at 5:00 PM EDT, these intriguing and clinically applicable questions will be addressed during a complimentary* LIVE webinar, hosted jointly by The Journal of Bone & Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT).
JBJS co-authors Mark E. Easley, MD, and Manuel J. Pellegrini, MD, will discuss findings from a systematic quantification of the stabilizing effects of subtalar joint soft-tissue constraints in a novel cadaveric model.
JOSPT co-author John M. van Ochten, MD, will share the results of a systematic review of randomized controlled and controlled clinical trials on the effectiveness of treatments for ankle sprains.
Moderated by Dr. Alexej Barg, a leading authority on the foot and ankle and traumatic injuries to the lower extremity, the webinar will include additional insights from expert commentators J. Chris Coetzee, MD, and Phillip A. Gribble, PhD, ATC, FNATA. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.
Seats are limited, so Register Now.
* This webinar is complimentary for those who attend the event live and will continue to be available at no charge for 24 hours following its conclusion.
OREF Grants Boost Rate of Future NIH Funding Success
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from John J.Callaghan, MD.
On October 2, 1955, Alfred R. Shands Jr and five other visionaries in the field of orthopaedic surgery—Joseph S. Barr, James A. Dickson, Francis M. McKeever, Harold A. Sofield, and Philip D. Wilson—convened in New York City for the first meeting of the Board of Trustees of the Orthopaedic Research and Education Foundation. They determined that orthopaedic medicine was changing so dramatically in scope and speed that a new, more scientific basis was needed to address the specialty’s evolution. They believed the research most likely to have an impact on the specialty should be conducted primarily by orthopaedic surgeons, who would also set the research agenda.
They realized that for this model to succeed, orthopaedic surgeons and the orthopaedic industry would have to make a firm commitment to support research grants. They hoped that providing seed money grants to young researchers would give a jump start to careers that might have a great impact on the field of orthopaedics. The goal of OREF was both to support research and the researchers who would make a difference in the future.
The responsibility of any fundraising foundation is to steward donations to accomplish the stated mission of the organization and thereby demonstrate the value of donor contributions to both donors and the organization. In the August 16, 2017 issue of JBJS, Hegde et .al. evaluate the success of OREF grant awardees in garnering subsequent principle-investigator National Institutes of Health (NIH) grants during the period between 1994 and 2014. In addition, they explore the researcher profile of an OREF grantee who successfully obtained NIH support.
The authors report a 22% rate of garnering NIH awards among OREF grant recipients, and a 46% rate for OREF Career Development Grant recipients. Combined MD/PHD recipients had a higher rate of NIH funding, as did grants for basic science projects. Grantees who later received NIH funding had higher scholarly productivity and publication experience. The success rate for subsequent NIH funding was higher among OREF grant recipients than the overall 18% rate for NIH funding success, which includes established investigators.
The findings from this study provide important previously unreported information for young investigators, loyal OREF donors, potential future OREF donors, research mentors and mentees, and the hard-working volunteer fundraisers and grant reviewers for the OREF. The data should encourage all who recognize the importance of innovative research in making orthopaedic surgery what it is today and to ensure continued advancements in the future.
The founding fathers of the Orthopaedic Research and Education Foundation would be proud to know their vision was and continues to be accomplished more than 60 years later. Hats off to these authors for this valuable contribution to our orthopaedic literature and the advancement of orthopaedic research.
John J. Callaghan, MD is professor of orthopaedics, rehabilitation, and biomedical engineering at the University of Iowa and a Past President of the Orthopaedic Research and Education Foundation.
Longer Surgeries, Lengths of Stay Associated with More Adverse Events
The phrase “adverse event” has been defined variably in the orthopaedic literature, which is one reason identifying the factors associated with such events can be tricky. In the August 16, 2017 edition of The Journal of Bone & Joint Surgery, Millstone et al. go a long way toward pinpointing modifiable factors that boost the risk of adverse events.
Using an institution-wide adverse-event reporting system called OrthoSAVES, the authors analyzed adverse events among 2,146 patients who underwent one of three elective orthopaedic procedures: knee replacement, hip replacement, or spinal fusion. They found an overall adverse event rate of 27%, broken down by surgical site as follows:
- 29% for spine
- 27% for knee
- 25% for hip
The most common adverse events had a low severity grade (1 or 2); the authors suggest that including events typically not viewed as severe (such as urinary retention) is one reason the overall adverse event rate in this study was higher than most previously reported.
The unique finding from this study was that two modifiable factors—length of stay and increasing operative duration—were independently associated with a greater risk of an adverse event. More specifically, the authors found that, regardless of surgical site, each additional 30 minutes of surgery increased the adjusted odds for an adverse event by 13%.
The authors were quick to point out that their findings should not be interpreted as an admonition for surgeons to hurry up. “While operative duration may be a modifiable factor, operating more quickly for spinal or any other procedures may, itself, lead to increased complications,” they wrote. Rather, Millstone et al. suggest that the multiple factors comprising “procedural efficiency” during a surgical hospitalization warrant further investigation.
What’s New in Musculoskeletal Infection
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, Arvind Nana, MD, co-author of the July 19, 2017 Specialty Update on musculoskeletal infection, selected the five most compelling findings from among the more than 120 studies cited in the Specialty Update.
Periprosthetic Joint Infection
–Much of the discussion around treating periprosthetic joint infections (PJIs) centers around comparing one-stage versus two-stage exchange arthroplasty. Two-stage exchange arthroplasty requires the use of a temporary cement spacer, and one study1 found that debris from articulating spacers may induce CD3, CD20, CD11(c), and IL-17 changes, raising the possibility of associated immune modulation.
–When performing debridement to treat a PJI, instead of an irrigation solution containing antibiotics, a 20-minute antiseptic soak with 0.19% vol/vol acetic acid reduced the risk of reinfection.2
Spine
–Four studies helped bolster evidence that surgical-site infections are the leading cause of reoperations after spine surgery, both early (within 30 days)3, 4 and late (after 2 years).5, 6
Trauma
–A 100-patient prospective cohort study found that posttraumatic osteomyelitis treated with a 1-stage protocol and host optimization in Type B hosts resulted in 96% infection-free outcomes.7
Shoulder
–As in lower-extremity procedures, the risk of infection after shoulder arthroplasty and arthroscopy is higher when the surgeries are performed less than 3 months after a corticosteroid injection. This finding suggests elective shoulder procedures should be delayed for at least 90 days after such injections.8
References
- Singh G, Deutloff N, Maertens N, Meyer H, Awiszus F, Feuerstein B, Roessner A, Lohmann CH. Articulating polymethylmethacrylate (PMMA) spacers may have an immunomodulating effect on synovial tissue. Bone Joint J. 2016 ;98-B(8):1062–8.
- Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic acid as part of a debridement protocol during revision total knee arthroplasty. J Arthroplasty. 2017 ;32(3):953–7. Epub 2016 Sep 28.
- Medvedev G, Wang C, Cyriac M, Amdur R, O’Brien J. Complications, readmissions, and reoperations in posterior cervical fusion. Spine (Phila Pa 1976). 2016 ;41(19):1477–83.
- Hijas-Gómez AI, Egea-Gámez RM, Martínez-Martín J, González-Díaz RC, Losada-Viñas JI, Rodríguez-Caravaca G. Surgical wound infection rates and risk factors in spinal fusion in a university teaching hospital in Madrid, Spain. Spine. November 2016.
- Ohya J, Chikuda H, Takeshi O, Kato S, Matsui H, Horiguchi H, Tanaka S, Yasunaga H. Seasonal variations in the risk of reoperation for surgical site infection following elective spinal fusion surgery: a retrospective study using the Japanese diagnosis procedure combination database. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 22.
- Ahmed SI, Bastrom TP, Yaszay B, Newton PO; Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine (Phila Pa 1976). 2016 . Epub 2016 Nov 9.
- McNally MA, Ferguson JY, Lau ACK, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 ;98-B(9):1289–96.
- Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 ;25(3):390–7. Epub 2015 Nov 30.
Maximizing Specialized Health Registries Under MIPS
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
I want to expand on my previous posts (Tips to Excel Under MIPS and Why EHR Data & Analytics Matter) and focus on another differentiating factor when it comes to electronic health record (EHR) systems and your success with Medicare’s Merit-based Incentive Payment System (MIPS).
The ability to interact with specialized health registries is another functionality your EHR system should have. Active engagement with a clinical data registry falls under the Advancing Care Information (ACI) component of MIPS. In general, having EHR-enabled access to such specialized health registries can make MIPS compliance easier and help you earn bonus points, which translates into increased practice income.
Some examples of orthopaedic-specific registries could include the following:
- Medial Meniscus Tear, Acute Registry
- Plantar Fasciitis Registry
- Low Back Pain
- Herniated Disc, Cervical Registry
In addition to having the ability to interact with orthopaedic-specific registries in order to participate in ACI and improve your MIPS score, registry engagement through your EHR system will help to improve population health by collecting and reporting on data about musculoskeletal treatment effectiveness and disease trends. Public health reporting can be very complicated and time-consuming, but having an EHR system that automatically and seamlessly collects and transmits the data to the registry, without manual intervention, is a robust advantage.
Finally, access to registry data will help your practice with the Improvement Activities component of MIPS, which, during the so-called transition year of 2017, is weighted at 15% of the total MIPS score.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
Attention PAs and NPs: JBJS JOPA CME Membership
Access the most relevant peer-reviewed orthopaedic content, including unlimited CME, by purchasing a 1-year JBJS JOPA CME membership—for the limited-time special rate of $99.
Your JBJS JOPA CME membership includes the following essential ingredients for your professional development and education:
- New JBJS Reviews CME every week
- Full access to JBJS Reviews and JBJS Journal of Orthopaedics for Physician Assistants (JOPA)
- Monthly Image Quizzes
- Annual PA Salary Survey
- Physical Exam and Injection Video Library
With more than 50 AMA PRA Category 1 CreditsTM available annually* with your membership, you can complete all your CME for under $100.
To obtain the special $99 rate, click here and enter code WHQ834AA at checkout.
*The Journal of Bone and Joint Surgery Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. JBJS designates each JBJS Reviews journal-based activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Rotator Cuff Repair Integrity is Important
Among the estimated 250,000 surgical rotator cuff repairs performed annually in the US, a growing percentage are being done on younger patients to prevent tear propagation and tissue degeneration. But how durable are the outcomes of those procedures?
In the August 16, 2017 issue of The Journal, Collin et al. report the 10-plus-year results of surgical repair of isolated supraspinatus tears. In this rather large cohort (288 patients with an average age of 57 years evaluated clinically, with 210 of those also evaluated with MRI), complications were not uncommon at 10.4%. On a more positive note, the average Constant score improved from about 52 before surgery to 78 at 10 years after surgery. The 10-year Constant scores correlated with MRI-determined repair integrity but were inversely associated with preoperative fatty infiltration of the supraspinatus.
These findings imply that careful patient selection based on both clinical factors and imaging studies is critically important in identifying patients with the best chance for good, long-term functional results. The presence of a cuff tear, particularly a large chronic one, is not always a surgical indication for repair. For example, Collin et al. found that the rate of retears was significantly higher in patients >65 years old than in those who were younger.
As is frequently the case in orthopaedics, we need additional prospective research with long-term functional and anatomic repair outcomes to better understand which patients are most likely to benefit from early repair of an isolated supraspinatus tear.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
For TKA Pain Relief, Motor-Sparing Blocks Last Longer than Periarticular Infiltration
Analgesia after total knee arthroplasty (TKA) is a multimodal affair these days. Main goals include maintaining adequate patient comfort while limiting opiate use and permitting early mobilization.
In the August 2, 2017 issue of JBJS, Sogbein et al. report on a blinded randomized study comparing the performance of two types of analgesia often used in multimodal TKA pain-management protocols: preoperative motor-sparing knee blocks and intraoperative periarticular infiltrations.
Prior to surgery, the 35 patients in the motor-sparing block group received a midthigh adductor canal block under ultrasound guidance, combined with posterior pericapsular and lateral femoral cutaneous injections. The 35 patients in the periarticular infiltration group received study-labeled local anesthetics intraoperatively, just prior to component implantation.
Defining the “end of analgesia” as the point at which patient-reported pain at rest or activity rated ≥6 on the numerical rating scale and rescue analgesia was administered, the authors found that the duration of analgesia was significantly longer for the motor-sparing-block group compared with the periarticular-infiltration group. The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no between-group differences in time to mobilization, length of hospital stay, opiate consumption, or functional recovery.
By Itself, Spine Surgery Not a Risk Factor for Prolonged Opioid Use
The use of prescription painkillers in the US increased four-fold between 1997 and 2010, and postoperative overdoses doubled over a similar time period. In the August 2, 2017 edition of The Journal of Bone & Joint Surgery, Schoenfeld et al. estimated the proportion of nearly 10,000 initially opioid-naïve TRICARE patients who used opioids up to 1 year after discharge for one of four common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis).
Eighty-four percent of the patients filled at least 1 opioid prescription upon hospital discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. Only 2 patients (0.02%) in this cohort continued prescription opioid use at 1 year following surgery.
In an adjusted analysis, the authors found that an age of 25 to 34 years, lower socioeconomic status, and a diagnosis of depression were significantly associated with an increased likelihood of continuing opioid use. Those patient-related factors notwithstanding, the authors claim that the outcomes in their study “directly contravene the narrative that patients who undergo spine surgery, once started on prescription opioids following surgery, are at high risk of sustained opioid use.”
However, in his commentary on this study, Robert J. Barth, PhD, cautions that the exclusion criteria restricted even this large sample to about 19% of representative spine surgery candidates, making the findings not widely generalizable. Having said that, the commentator adds that the study supports findings of prior research that persistent postoperative opioid use is more related to “addressable patient-level predictors” than postsurgical pain. He also notes that the findings are “supportive of guidelines that call for surgical-discharge prescriptions of opioids to be limited to ≤2 weeks.”
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