Risk Reduction Compared with Access to Care: The Trade-Off of Enforcing a BMI Eligibility Criterion for Joint Replacement
Morbidly obese patients with severe osteoarthritis benefit from successful total joint arthroplasty. However, morbid obesity increases the risk of complications. https://bit.ly/2qpfj8w #JBJS
Glenohumeral arthrodesis is a salvage operation, so most patients and surgeons considering this option don’t have expectations of spectacular functional outcomes. Improving stability and relieving pain are usually the main goals. In the April 4, 2018 edition of The Journal of Bone & Joint Surgery, a retrospective study by Wagner et al. sheds light on long-term results of this procedure (mean follow-up of 12 years) and the patient and surgical factors that might improve or worsen outcomes.
The authors reviewed electronic and paper medical records of 29 cases of glenohumeral arthrodesis performed between 1992 and 2009. They also analyzed patient questionnaires, which included DASH, SSV, and SF-36 scoring instruments.
All patients reported improvement in pain at the time of their latest postoperative follow-up. However, 12 patients (41%) had postoperative complications, including nonunions, fractures, and deep infections. Eleven patients (38%) required additional post-arthrodesis surgical procedures. The mean postoperative shoulder position was 60° in flexion and 13° in external rotation.
The authors identified the following correlations between patient/surgical factors and outcomes:
- Patients with a history of brachial plexus injuries had worse clinical and functional outcomes.
- Patients with shoulders fused in abduction and flexion of >25° had better shoulder function but a slightly higher risk of peri-fixation fracture.
- There were no significant outcome differences between procedures that used plate-and-screw and screw-only fixation. However, incorporation of the acromion in fixation was strongly associated with a lower risk of nonunion.
The authors conclude that despite the limitations of this complex salvage procedure, “its ability to relieve pain and to maintain reasonable upper-extremity function in select patients should not be overlooked.”
One goal of an orthopaedic surgery residency is to prepare residents for the procedures they will perform when they are attendings. Yet, until the retrospective cohort study by Kohring et al. in the April 4, 2018 issue of The Journal, it remained unclear how similar a resident’s surgical case mix was compared to the cases attendings saw in early practice. Kohring et al. used data from both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) to compare the types of procedures residents performed between 2010 and 2012 to the cases junior attendings submitted for the ABOS Part II examination between 2013 and 2015. The authors then categorized the cases by CPT codes and split them into adult and pediatric categories to allow for further comparison.
Here are a few interesting findings from the study:
- More than half of all adult and pediatric procedures performed during residency and by early-career attendings fell within the top 10 CPT code categories.
- Knee and shoulder arthroscopy were the most commonly performed cases in adults during both residency and early practice.
- Residents take part in total knee and total hip arthroplasties much more frequently than do attendings in early practice.
- Attendings in early practice treat more than twice the number of proximal femur fractures than do residents during residency.
- Residents are exposed to a much higher rate of spinal fusion cases than are seen by early-practice attendings.
Although the authors conclude that the “similarity between residency and early practice experience is generally strong,” this study highlights some of the disparities between the two cohorts, and these findings may inform further research aimed at improving training for orthopaedic surgeons. By themselves, however, these results should not be used to change the experience residents have during their training. The authors mention the limitations inherent when comparing these two cohorts, and I can testify that my clinical practice has evolved tremendously in the 3 years since I started as an attending.
Furthermore, with more than 90% of orthopaedic residents going on to complete a subspecialty fellowship immediately after residency, it is safe to say that the degree of similarity between residency and attending case experience will vary from surgeon to surgeon.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
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, Sanjeev Kakar, MD, author of the March 21, 2018 Specialty Update on Hand and Wrist Surgery, selected the five most clinically compelling findings from among the nearly 40 studies summarized in the Specialty Update.
Distal Radius Fractures
—When can a patient safely drive after surgical treatment of a distal radial fracture? According to a prospective study by Jones et al.1, most patients can do so within 3 weeks following surgery. Twenty-three patients had their driving evaluated 2 and 4 weeks after volar plating. Sixteen of the 23 patients drove safely on a closed course with both hands on their first attempt, which averaged 18 days after surgery.
—One factor contributing to scaphoid nonunion is impaired vascularity. So, if the proximal pole of the scaphoid is avascular, is the use of vascularized bone grafting mandatory? No, according to a prospective study by Rancy et al.2, which followed 35 scaphoid nonunion patients treated with curettage, nonvascularized bone grafting, and headless screw fixation. Nine of 23 proximal pole fractures demonstrated ischemia on MRI imaging; 28 of 33 were found to have impaired intraoperative punctate bleeding; and 18 patients had ≥50% tissue necrosis on pathological analysis. CT analysis revealed that 33 of the 35 scaphoids had healed by three months, leading the authors to conclude that nonvascularized bone grafting can suffice as long as the fracture is appropriately reduced and stabilized.
—Lichtman et al.3 introduced a new algorithm for Kienbock disease management that incorporates previous classification systems plus 5 treatment-guiding questions:
- How old is the patient?
- What is the effect of the disease on the lunate?
- How does the disease affect the wrist?
- What treatments are available?
- What are the patient’s requirements?
Depending on the answers, the authors present treatment options ranging from lunate reconstruction to wrist salvage.
—Some surgeons view radiographic evidence of a reverse oblique inclination in the sigmoid notch as a contraindication for ulnar shortening in patients with ulnar impaction. However, using MRI, Ross et al.4 noted that reverse oblique inclinations of the distal radioulnar joint, as seen on plain radiographs, were not evident when coronal MRI scans were analyzed. They concluded that some patients previously thought to have contraindications to ulnar shortening may in fact be suitable candidates for that procedure.
—Dwyer et al.5 evaluated an opioid-reduction strategy for patients undergoing carpal tunnel release or volar locking-plate fixation of distal radius fractures. Patients received education and encouragement to use over-the-counter (OTC) medications along with opioids. Among the carpal tunnel cohort (n = 121), the average opioid prescription was for 10 pills compared with 22 in the previous year. Average actual consumption was 3 opioid pills and 11 OTC pills. In the distal radius fracture group (n = 24), the average opioid prescription was 25 pills compared with 39 the year before. These patients consumed on average 16 opioid pills with 20 OTC pills. Patient satisfaction was high in both groups. The authors recommend that physicians prescribe 5 to 10 opioid pills for carpal tunnel release and 20 to 30 pills after volar plating for distal radius fractures.
- Jones CM, Ramsey RW, Ilyas A, Abboudi J, Kirkpatrick W, Kalina T, Leinberry C. Safe return to driving after volar plating of distal radius fractures. J Hand Surg Am. 2017 Sep;42(9):700-704.e2.
- Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW, Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol. 2017 Jan 1;1753193417732003.
- Lichtman DM, Pientka WF 2nd, Bain GI. Kienböck disease: a new algorithm for the 21st century. J Wrist Surg. 2017 Feb;6(1):2-10. Epub 2016 Oct 27.
- Ross M, Wiemann M, Peters SE, Benson R, Couzens GB. The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint. Bone Joint J. 2017 Mar;99-B(3):369-75.
- Dwyer CL, Soong MC, Hunter AA, Dashe J, Tolo ET, Kastayan NG. Prospective evaluation of an opioid reduction protocol in hand surgery. Read at the American Society for Surgery of the Hand Annual Meeting; 2017 Sep 7-9; San Francisco, CA. Paper no. 5.
In 1922, Kellogg Speed, MD said in his American College of Surgeons address, “We enter the world under the brim of the pelvis and exit through the neck of the femur.” Since then, it has been repeatedly shown that femoral-neck and intertrochanteric hip fractures are associated with a high mortality rate during the first year following fracture. Now, in the era of widespread hip arthroplasty—and with the consequently increasing rates of periprosthetic fractures near the hip joint—it is relevant to ask whether periprosthetic fractures are associated with an increased risk of mortality similar to that seen after native hip fractures. In the April 4, 2018 issue of The Journal, Boylan et al. use the New York Statewide Planning and Research Cooperative System database to address that question.
The authors reviewed 8 years of native and periprosthetic hip fracture data to determine whether the 1-month, 6-month, and 12-month mortality risk between the two patient cohorts was similar. They found that the 1-month mortality risk in the two groups was similar (3.2% for periprosthetic fractures and 4.6% for native fractures). However, there were significant between-group differences in mortality risk at the 6-month (3.8% for periprosthetic vs 6.5% for native) and 12-month (9.7% vs 15.9%) time points.
This makes clinical sense because, in general, patients experiencing a native hip fracture have lower activity levels and general fitness and higher levels of comorbidity than patients who have received a total hip arthroplasty. Extensive research has resulted in protocols for lowering the risk of mortality associated with native hip fractures, such as surgery within 24 to 48 hours, optimizing medical management through geriatric consultation, and safer and more effective rehabilitation strategies. We need similar research to develop effective perioperative protocols for patients experiencing a periprosthetic fracture, as this study showed that 1 out of 10 of these patients does not survive the first year after sustaining such an injury. I also agree with the authors’ call for more research to identify patients with periprosthetic fractures who are “at risk of worse outcomes at the time of initial presentation to the hospital.”
Marc Swiontkowski, MD
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects
S D Boden, D O Davis, T S Dina, N J Patronas, S W Wiesel: JBJS, 1990 March; 72 (3): 403
Many important subsequent studies were inspired by the findings of this landmark JBJS study. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRI is variable; and that all imaging information must be correlated to the patient’s clinical condition.
A Conservative Operation for Bunions
E D McBride: JBJS, 1928 October; 10 (4): 735
Many other bunion procedures have been described since 1928, but the principle of restoring congruency of the first metatarsophalangeal joint remains very important in bunion operations. The most substantial modification of McBride’s procedure is that the lateral sesamoid is no longer typically excised.
According to the CDC, in 2013, the total national arthritis-related medical care costs and earnings losses among adults were $303.5 billion, or 1% of the 2013 US Gross Domestic Product.
One response to statistics like that is the notion of “value-based health care.” How far has the orthopaedic community moved from a volume/fee-for-service-based model to one in which patients achieve the best possible musculoskeletal outcomes, payers expend the fewest possible dollars, and providers throughout the episodes of care are fairly compensated for their skill and compassion?
On Thursday, April 12, 2018 at 8:00 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar that will answer these thorny questions by discussing the cost drivers behind the problem, where arthritis management stands currently, and where the value-based care bandwagon is heading.
Kevin Shea, MD, an expert in developing clinical practice guidelines, will discuss the crucial differences between “irrational variation” and “rational, patient-centered variation.”
Antonia Chen, MD, director of arthroplasty research at Harvard Medical School, will demystify the many attempts to measure and improve the quality of joint replacement and will address quality and value in the nonoperative management of osteoarthritis.
Gregory Brown, MD, a Tacoma, Washington-based surgeon specializing in knee reconstruction, will peer into the future of health insurance, patient empowerment, and robust orthopaedic registries.
Moderated by Douglas Lundy, MD, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.