Archive | June 2018

Minimum Five-Year Outcomes of Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Labral Tears in Patients with Obesity

Obesity is a negative prognostic factor for various surgical procedures. https://bit.ly/2JKUj4C #JBJSInfographics #VisualAbstract

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Inability of Older Adult Patients with Hip Fracture to Maintain Postoperative Weight-Bearing Restrictions

For elderly trauma patients, a basic goal is early mobilization, as immobilization can trigger various complications, such as venous thromboembolism, pneumonia, urinary tract infections, and pressure ulcers. https://bit.ly/2JIILyU #JBJSInfographics #JBJSVideoSummaries #VisualAbstract

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Sarcopenia: An Independent Predictor of Mortality in Geriatric Acetabular Fractures

PLVIOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in the Journal of Orthopaedic Trauma.

Fractures in the elderly are a growing problem in developed countries and generally carry a significant morbidity and mortality burden. When considering treatment strategies and making prognoses in this patient population, our ability to stratify patient frailty may be just as or more important than classifying the fracture. In a recent study in the Journal of Orthopaedic Trauma, Mitchell et al. evaluate the role of sarcopenia, an age-related loss of muscle mass, in predicting 1-year mortality among elderly patients with acetabular fractures.1

The authors performed a retrospective review of nearly 150 patients >60 years of age who sustained an acetabular fracture between 2003 and 2014. The authors used the lowest quartile of the psoas:lumbar vertebral index (PLVI) in the cohort as a surrogate for sarcopenia. The PLVI is calculated by measuring the cross-sectional area of the psoas muscle bellies at the L4 level and dividing that number by the cross-sectional area of the L4 vertebral body measured at the superior endplate (see image). Lower PLVIs represent greater loss of muscle mass.

After controlling for confounding variables, the authors found that sarcopenia was an independent risk factor for 1-year mortality. Specifically, patients with sarcopenia had a 32.4% 1-year mortality rate compared to a rate of 11.0% in patients without sarcopenia. Age and injury severity score (ISS) were also predictive of 1-year mortality, and patients with all 3 factors (age >75 years, ISS >14, and sarcopenia) had a mortality rate of 90%.

This article highlights the importance of risk-stratifying patients in ways that account for more than their presenting injuries. In the elderly population, chronologic age is only one of many indicators of frailty. Sarcopenia may be another marker that we can use to better understand the general well-being of our patients. As Mitchell et al. mention, more research must be done to precisely define a PLVI cutoff for sarcopenia to make this index a clinically useful tool. Ultimately, doing so will allow us to offer elderly patients and their families more thoughtful and evidence-based counseling regarding treatment and prognosis.

Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.

Reference

  1. Mitchell, Phillip M., et al., Sarcopenia is Predictive of 1-year Mortality After Acetabular Fractures in Elderly Patients.” Journal of Orthopaedic Trauma, June 2018; 32 (6) : 278-282.

JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing

JBJS 100Under 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:

Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.

A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.

ADHD and a Drug that Treats It Raise Risk of Some Fractures

Stress Fx for OBuzz Few physicians or patients associate attention deficit hyperactivity disorder (ADHD) with an increased risk of traumatic or stress-related fractures. However, in the June 6, 2018 issue of JBJS, a study by Ben-Ami et al. corroborates previous research suggesting that such associations exist. The authors evaluated 100,000 Israeli Defense Forces recruits and found that subjects diagnosed with ADHD were significantly more likely to sustain a traumatic fracture than recruits having no ADHD diagnosis. Furthermore, they found that recruits with ADHD who were taking the stimulant methylphenidate to treat their symptoms had a significantly increased risk of sustaining a stress fracture compared to both recruits without ADHD and recruits who had ADHD but did not take the medication.

The association between methylphenidate exposure and increased risk of stress fracture makes sense, based on animal studies showing that the drug leads to increased bone resorption. However, until now I was unaware that patients with ADHD are at an increased risk of traumatic fracture as well. The authors postulate that such an association is secondary to the fact that ADHD often manifests with compulsive or inattentive behavior that may predispose these patients to injuring themselves. That theory is further supported by this study’s finding that the risk of traumatic fracture fell when those with ADHD took stimulant medications to control their symptoms.

When one considers that upwards of 5% of school-aged children and another 4% of  adults in the US are prescribed stimulant medication (not to mention the estimated 5% to 35% of US college students who abuse stimulants without prescription), these findings take on great importance.  Because of the large number of children and adults who rely on methylphenidate to control ADHD symptoms, it is important for both primary care physicians and orthopaedic surgeons to understand the association between this medication and stress fractures.

Although limited by the vulnerabilities typically found in observational, retrospective designs, this study’s findings add to a growing body of evidence highlighting the potential fracture risks associated with stimulant medication. We probably encounter patients taking such medications on a regular basis in our practices. These data should prompt us to ask more questions of patients who have sustained stress fractures to determine whether stimulant medication usage may be an underlying cause.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Orthopaedic Surgeons Hate Fixation Failures

IM Nail for Hip Fx for OBuzzFew things are more disheartening to an orthopaedic surgeon than taking a patient back into the operating suite to treat a failure of fixation. In part, that’s because we realize that the chances of obtaining stable fixation, especially in elderly patients with poor bone density, are diminished with the second attempt. We are additionally cognizant of the risks (again, most significant in the elderly) to cardiopulmonary function with a second procedure shortly after the initial one.

These concerns have led us historically to instruct patients to limit weight bearing for 4 to 6 weeks after hip-fracture surgery. On the other hand, we have seen evidence in cohort studies to suggest that instructing elderly patients with proximal femur fractures to bear weight “as tolerated” after surgery is safe and does not increase the risk of fixation failure.

In the June 6, 2018 issue of The Journal, Kammerlander et al. demonstrate that 16 cognitively unimpaired elderly patients with a proximal femur fracture were unable to limit postoperative weight bearing to ≤20 kg on their surgically treated limb—despite 5 training sessions with a physiotherapist focused on how to do so. In fact, during gait analysis, 69% of these elderly patients exceeded the specified load by more than twofold, as measured with insole force sensors. This inability to restrict weight bearing is probably related to balance and lower-extremity strength issues in older patients, but it may be challenging for people of any age to estimate and regulate how much weight they are placing on an injured lower limb.

With this and other recent evidence, we should instruct most elderly patients with these injuries to bear weight as comfort allows and prescribe correspondingly active physical therapy. As surgeons, we should focus our efforts on the quality and precision of fracture reduction and placement of surgical implants. This will lead to higher patient, family, and physical-therapist satisfaction and pave the way for a more active postoperative rehabilitation period and better longer-term outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

June 2018 Article Exchange with JOSPT

jospt_article_exchange_logo1In 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 June 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis.”

The authors issue a clear “call to action” for exercise therapy in patients with hip and knee osteoarthritis (OA), not only because it reduces arthritis symptoms, but also because physical activity helps prevent at least 35 chronic conditions and helps treat at least 26 chronic conditions.

Bunion Treatments Abound Amid Multiple Etiologies

Bunionectomy for OBuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS, in response to a recent study in Foot and Ankle Clinics of North America.

It makes sense that orthopaedic conditions with multiple etiologic factors have a corresponding variety of treatment options. So it is with hallux valgus (bunion deformity). In the June 2018 edition of Foot and Ankle Clinics of North America, Smyth and Aiyer1 focus on the pathoanatomy of hallux valgus and various approaches to selecting an operative option.

With more than 100 different operative procedures described to correct hallux valgus, it can be challenging to pick the “right” procedure for each patient. The etiology of hallux valgus includes intrinsic factors (e.g., a long first metatarsal, the shape of the metatarsal head, and soft-tissue imbalances across the hallux metatarsophalangeal [MP] joint) and extrinsic factors (e.g., high-heeled, narrow toe-box shoes). Other kinematic factors of the foot, such as hypermobility of the first ray, are associated with hallux valgus, as is pes planus (flatfoot). Whatever the etiology, hallux valgus almost always progresses in a relatively predictable manner.1

Careful preoperative analysis is required to successfully treat hallux valgus, with the goal of restoring static and dynamic balance around the first MP joint. For optimum outcomes, a soft-tissue procedure (e.g., modified McBride procedure) is now commonly combined with osseous corrective techniques. The chevron osteotomy, which has been modified in multiple ways, achieves acceptable outcomes with reportedly high patient satisfaction levels, as does a percutaneous distal metatarsal osteotomy.2

More severe deformities are usually treated with proximal first metatarsal osteotomies—such as  a proximal chevron, Ludloff osteotomy, or Scarf osteotomy—to increase the possible angular correction of the metatarsal. While these procedures are more “powerful” correction options, some studies have shown recurrence rates up to 30% at 10 years of follow up.1,2 In cases of severe deformity accompanied by arthritis of the tarsometatarsal (TM) joint, a modified Lapidus procedure may be an option for stabilizing the first TM joint. Hallux MP arthrodesis is also considered in patients who have severe deformity, arthritis, and neuromuscular disorders, and for the revision of a previously failed hallux valgus surgery.

There is currently no consensus as to which procedure is the gold standard for treating hallux valgus. Despite multiple comparative studies assessing the outcomes of different techniques, the decision ultimately depends on surgeon and patient preferences.

Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh and a member of the JBJS Social Media Advisory Board.

References

  1. Smyth NA & Aiyer AA 2018, ‘Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?’, Foot and Ankle Clinics, 23, no.2, pp.171-182.
  2. Adams SB, 2017, JBJS Clinical Summary: Hallux Valgus (Bunion Deformity), viewed 27 may 2018, https://jbjs.org/summary.php?id=188

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