Archive | March 2019

Weight Training-Induced Bilateral Knee Dislocation

You know you’re having a bad day at the gym when both your knees dislocate during a leg-press workout. That is what happened to a 44-year-old male recreational weight lifter who  “locked out” both his knees while trying to press 1,100 lbs. This unusual case is described in the latest issue of JBJS Case Connector.

Knee joint dislocations are true emergencies because of the potential for concomitant neurovascular injury. This patient was transferred to a tertiary academic hospital for emergency closed reduction and application of knee-spanning external fixators. Although both tibiae were dislocated anteriorly, both lower extremities were neurovascularly intact.

One month after the initial injury, the external fixators were removed and the knees were placed in bilateral hinged braces. MRI performed shortly thereafter revealed tears of multiple ligaments and distal popliteus tendon tears in both knees. At 4 months postinjury, the patient underwent left-side ACL reconstruction, PCL reconstruction, FCL repair and reconstruction, popliteal reconstruction with allograft, and a popliteofibular ligament reconstruction. Seven months after that, he underwent similar procedures on the right side.

At the most recent postsurgical follow-up, 17 months after the initial injury, the range of motion in both knees was 0° to 130°, and the patient was able to participate in straight line running, squats, and cycling.

The authors emphasize that any locking of the knees results in 5° to 10° of hyperextension, which places an increased load across the ACL. Add to that the heavy weight and the abrupt increase in velocity at the extreme range of motion, and you have a recipe for serious injury. The authors conclude that “the risk of knee dislocation can be reduced by avoiding locking and hyperextension of the knees during any type of leg press or squatting exercise.”

For more information about JBJS Case Connector, watch this video featuring JBJS Editor in Chief Dr. Marc Swiontkowski.

Don’t Overlook Possible Osteoid Osteoma in Kids with Hip Pain

Orthopaedists are seeing an increasing number of active, young patients with hip pain. A study by May et al. in the March 20, 2019 issue of The Journal of Bone & Joint Surgery strongly suggests that osteoid osteoma (OO)—a small, benign tumor characterized by dense sclerotic bone tissue—should not be overlooked in the differential diagnosis when working up these patients.

The authors identified and reviewed the records of 50 children and adolescents (mean age of 12.4 years) at their tertiary-care pediatric center who had received a diagnosis of OO within or around the hip between 2003 and 2015. Nighttime hip and/or thigh pain (90%) and symptom relief with NSAIDs (88%) were common clinical findings.

Sclerosis/cortical thickening was visible in 58% of the radiographs. Perilesional edema and a radiolucent nidus was found on all 43 of the available CT scans, leading the authors to conclude that “CT scans provide definitive diagnosis” of OO.

Unfortunately, 46% of these patients initially received an alternative diagnosis, the most common of which was femoroacetabular impingement (FAI), and a delay in diagnosis of >6 months occurred in 43% of patients. The authors note that concerns regarding radiation exposure have led some clinicians to order MRI rather than CT when evaluating pediatric hip disorders, but this study found that identifying an OO nidus with MRI was not as accurate as doing so with CT.

Regarding treatment, among the 41 patients who ultimately underwent percutaneous radiofrequency ablation (RFA) to treat OO, 93% achieved complete post-RFA symptom resolution. Complications from RFA occurred in 7% of patients who underwent the procedure.

Autophagy: A Culprit in Aseptic Implant Loosening?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

Periprosthetic membranes are fibrous granulomatous tissues composed of wear debris and numerous cell types, including fibroblasts, macrophages, osteoclasts (OCs), osteoblasts (OBs), osteocytes (OSTs), mesenchymal stem cells (MSCs), synovial cells, endothelial cells, and, rarely, lymphocytes. Macrophages ingest wear debris, resulting in the production of proinflammatory factors such as tumor necrosis factor (TNF); interleukin (IL)-1, IL-6, IL-17; macrophage colony-stimulating factor (M-CSF); and reactive oxygen species. In addition, macrophages can differentiate into OCs, which can induce the fibroblast cytokines that contribute to bone resorption.

Autophagy is the basic catabolic mechanism that degrades/recycles unnecessary or dysfunctional cellular components through the action of lysosomes. The breakdown of cellular components promotes cellular survival during stress, such as starvation, by maintaining cellular energy levels. In most instances, autophagy does not lead to cell death. Although the products of autophagy are typically recycled intracellularly, they may also be secreted.

Autophagy is also important for the differentiation of OBs, OSTs, and OCs. In addition, autophagy is involved in OB mineralization, and autophagy proteins are required for OC bone resorption. Autophagy appears to be triggered by wear debris in OCs, OBs, and macrophages, where the process promotes the secretion of proinflammatory proteins associated with the development of aseptic loosening. Autophagy can also be involved in the secretion of proteins such as chemokine (C-C motif) ligand 2 (CCL2) and leukemia inhibitory factor (LIF), which were both overexpressed in aseptic loosening in a rat model.

Autophagy inhibition has been shown to decrease osteolysis severity in animal models. For example, 3-methyladenine inhibition of the autophagy response to TiAl6V4 particles improved bone microarchitecture in a murine calvaria resorption model. Although autophagy will probably not be the final answer for prosthetic loosening, it is an avenue that should prompt future research into new therapeutic approaches.

Reference
Camuzard O, Breuil V, Carle GF, Pierrefite-Carle V. Autophagy Involvement in Aseptic Loosening of Arthroplasty Components. J Bone Joint Surg Am. 2019 Mar 6;101(5):466-472. doi: 10.2106/JBJS.18.00479. PMID: 30845042

 

The Journal Joins You on Instagram

The Journal of Bone & Joint Surgery has been a valuable resource for the orthopedic community since 1889, when the Transactions of the American Orthopedic Association first published proceedings from the 1887 and 1888 meetings. The Journal has continued to provide gold-standard information to clinicians, researchers, and orthopaedic care teams to support the mission of improving musculoskeletal health across the globe. As new platforms and novel avenues for sharing information and ideas have taken shape, we have used these opportunities to improve global access to essential knowledge and learning resources to foster excellence in patient care.

In continuing that mission, we are pleased to join the orthopaedic community on Instagram! Our goal is to help followers stay up-to-date with the highest quality orthopaedic literature. Each post will highlight new information from a variety of sources and include links to original content. We hope that this new social media presence for The Journal will serve as yet another tool to help you stay informed about what’s new and important in orthopaedic surgery.

Follow JBJS on Instagram @the_jbjs.

#JBJS #OrthopaedicSurgery #EvidenceBasedMedicine

What’s New in Hand Surgery 2019

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.

This month, Christopher J. Dy, MD, MPH, author of the March 20, 2019 “What’s New in Hand Surgery,” selected the five most compelling findings from among the 47 noteworthy studies summarized in the article.

Distal Radial Fractures
—A randomized trial comparing volar plate fixation to cast management in patients >60 years of age who had AO type-C distal radial fractures1 found that the volar plating group had better Patient-Rated Wrist Evaluation scores than the casting group after a minimum 24 months of follow-up. Maintenance of reduction was also better in the volar plating group. These findings are contrary to those of a similar randomized trial published in 2011, suggesting that there are patient-level and surgeon-level differences between the 2 environments in which the studies were conducted.

—Among 175 elderly patients with distal radial fractures treated nonoperatively and who showed acceptable radiographic reduction at 1 to 2 weeks, 28% had late displacement or malunion at the 3-month follow-up.2 Relative to cases in which reduction was maintained, cases with late displacement or malunion had lower grip strength and loss of the total wrist range of motion. However, there was no between-group difference in patient-reported functional measures, and the incidence of the most common complication—carpal tunnel syndrome—was the same in both groups.

Scaphoid Fractures
—Findings from a biomechanical study with cadavers suggest that 50% cortical healing of a scaphoid fracture after open reduction and internal fixation with a compression screw is sufficient to allow unrestricted activity.3 Constructs with a 50% osteotomy and compression screw showed the same load to failure as intact scaphoids, but load to failure in a group with a 75% osteotomy and compression screw was lower than that in the intact scaphoid group.

—Traditionally, surgeons have emphasized proximal pole vascularity in cases of scaphoid nonunion. However, a study of 35 scaphoid nonunions treated with nonvascularized bone grafting and a headless compression screw4 found that 33 fractures went on to union, despite evidence of compromised proximal pole vascularity in 14 of 32 patients who had histopathological data available.

Carpal Tunnel Syndrome
—A cross-sectional study analyzing data from 367 patients who presented for evaluation of carpal tunnel syndrome (CTS)5 found that those with the poorest socioeconomic status had worse PROMIS scores for physical function, pain interference, depression, and anxiety, compared with those in the least-deprived quartile. Deprived patients were also more likely to have a higher comorbidity burden and to use tobacco, both of which may influence outcomes after CTS treatment.

References

  1. Martinez-Mendez D, Lizaur-Utrilla A, de-Juan-Herrero J. Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating. J Hand Surg Eur Vol.2018 Feb;43(2):142-7. Epub 2017 Sep 4
  2. Wadsten MÅ, Sjödén GO, Buttazzoni GG, Buttazzoni C, Englund E, Sayed-Noor AS. The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life. J Hand Surg Eur Vol.2018 Feb;43(2):131-6. Epub 2017 Jul 31.
  3. Guss MS, Mitgang JT, Sapienza A. Scaphoid healing required for unrestricted activity: a biomechanical cadaver model. J Hand Surg Am.2018 Feb;43(2):134-8. Epub 2017 Nov 7.
  4. 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.2018 Jan;43(1):32-40. Epub 2017 Sep 24.
  5. Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2018 Jun 23. [Epub ahead of print].

Revisiting INR Targets Prior to TKA

An elevated International Normalized Ratio (INR)—a standardized gauge for how long it takes blood to clot—is rarely a good sign when someone is about to undergo an elective orthopaedic procedure. This is especially true for larger surgeries such as total hip or knee arthroplasty, in which there are already concerns about perioperative bleeding. Excessive surgery-related blood loss can lead to wound complications, increased length of hospital stay, and higher mortality rates. But what precisely constitutes an “elevated” INR? While some recommendations suggest that elective procedures be performed only when a patient’s INR is ≤1.5, the evidence supporting this recommendation, especially in the setting of total knee arthroplasty (TKA), is sparse at best.

In the March 20, 2019 issue of The Journal, Rudasill et al. use the National Surgical Quality Improvement Program (NSQIP) database to help define what “elevated” should mean in the context of TKA. They evaluated data from >21,000 patients who underwent a TKA between 2010 and 2016 and who also had an INR level reported within one day before their joint replacement. They stratified these patients based on their INR levels (≤1, >1 to 1.25, >1.25 to 1.5, and >1.5). Using multivariate regression analysis to adjust for patient demographics and comorbidities, the authors found a progressively increasing risk of bleeding requiring transfusion for each group with an INR >1 (odds ratios of 1.19, 1.29 and 2.02, respectively).  Relative to patients with an INR of ≤1, Rudasill et al. also found a significantly increased risk of infection in TKA patients with an INR >1.5 (odds ratio 5.34), and an increased risk of mortality within 30 days of surgery among patients with an INR >1.25 to 1.5 (odds ratio 3.37). Lastly, rates of readmission and the length of stay were significantly increased in patients with an INR >1.25.

While there are certainly weaknesses inherent in using the NSQIP dataset, this study is the first to carefully evaluate the impact of slight INR elevations on post-TKA morbidity and mortality. While I was not surprised that increasing INR levels were associated with increased bleeding events, I was impressed by the profound differences in length of stay, infection, and mortality between patients with an INR ≤1 and those with an INR >1.25. I agree with the authors’ conclusion that “current guidelines for a target INR of <1.5 should be reconsidered for patients undergoing TKA.”  Further, based on the risks highlighted in this study, prospective or propensity matched cohort studies should be performed to help determine whether anyone with an INR >1 should undergo a TKA.

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

Changing Workplace Culture to Avoid Physician Burnout

In the February 6, 2019 issue of JBJS, David A. Rothenberger, MD contributed a thoughtful and practical “What’s Important” article about how to foster well-being among physicians and thus reduce the risk of physician burnout.

Since the article’s publication, Dr. Rothenberger has received many comments from readers. Here are several, de-identified to protect privacy, along with some responses from Dr. Rothenberger:

In my opinion, the internal culture of medicine, and specifically surgery, is to blame for poor mental health, burnout, and depression… [Surgeons are] trying to make up declining reimbursement by working harder. .. I too lived in that culture and relished being the busiest surgeon in the system, knocking out 10 to 12 operations a day,… but after the age of 50, I began noticing age catching up and increasing negativity within the profession. That is about when I decided to bail out. I have never looked back, although I miss my patients. Our profession… rewards self-punishment. Like you, I am hopeful that this will change for future physicians… My hope is that the welcome influx of women physicians will teach us misguided men a thing or two about taking care of oneself, one’s family, and understanding the limits of what we can do.

 

I believe burnout, in my case, was caused by, among other things, the destruction of our fee schedules… My brightest child wanted to follow in my footsteps, and I talked him out of it… I feel society has forsaken us.  I plan to quit this November, and it’s not soon enough.

To which Dr. Rothenberger replied as follows:
“I understand your decision to leave medicine,… but my advice is ‘do not go it alone.’ Get some support from someone you trust who understands this predicament… Plan for your future after medicine.  Re-imagine your life.”

 

I know a lot of physicians here who have problems in their practice, including a lot of my partners. I think the concept of a Chief Wellness Officer [CWO] is a great idea. I plan on forwarding [your “What’s Important” article] to our administration.

To which Dr. Rothenberger replied as follows:
“A CWO will help only if the other leaders of your system are committed to changing the culture of the workplace.  It is not an easy undertaking, but I think the return on investment justifies the multiyear approach we are taking here [at the University of Minnesota].”

 

It is really meaningful that you have emphasized that this is a bigger issue than the individual. I believe you are absolutely correct in highlighting a culture shift that prioritizes giving…factors [such as autonomy] back to physicians. [That] is probably the single most effective way to turn this around.

I am finishing my orthopedic residency… Our hospital system occasionally holds “wellness activities” that typically include massage and similar events, but these often don’t work with a busy surgeon’s schedule.  I’m interested in making burnout prevention a more recognized issue within our department and want to help bring in resources to help our residents and staff, but I am struggling with how best to practically bring this about. Do you have any advice for integrating wellness resources and burnout prevention into a busy orthopaedic department?

To which Dr. Rothenberger replied as follows:
“Wellness activities” like massage, yoga, and exercise classes are often put together by Human Resources for the workforce at large.  They are useful to individuals but do little to change the workplace culture… Our effort here at the University of Minnesota is to build a Well-Being Alliance of health care professionals who are working together as a coalition of the willing to restore well-being and joy to the practice of medicine.  We will do this by changing our workplace culture—a multiyear effort.  Features of our Alliance are that it is

  1. Interprofessional (i.e., it involves MDs, nurses, pharmacists, etc.)
  2. Longitudinal (i.e., it includes students; residents and fellows; early, mid and late-career physicians; and retired members of our community)
  3. Evidence-based as much as possible, and
  4. Financially and operationally sustainable.”

These issues of physician wellness and burnout prevention need to be highlighted locally, and local resources need to be brought to bear to address the challenge. I’m grateful to be at the University of Minnesota, where Dr. Rothenberger and the Well-Being Alliance are tackling the problem in meaningful ways.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Preventing VTE in Below-the-Knee Surgery

Venous thromboembolism (VTE) following hip fractures and hip/knee arthroplasty—both deep vein thrombosis (DVT) and pulmonary embolism (PE)—has been relatively well studied. We therefore have a fairly clear understanding what the risks for DVT and PE are with no treatment as well as with modern preventive chemotherapeutic agents. However, such clarity on the need for and effectiveness of VTE prophylaxis is lacking for below-the-knee (BTK) orthopaedic procedures. This is largely due to the fact that such procedures have been deemed “low risk”—despite a dearth of supporting evidence for that assumption. In the March 20, 2019 issue of The Journal, Heijboer et al. used a sophisticated propensity score matching methodology to evaluate the rate of VTE in >10,000 BTK surgery patients at their tertiary care referral center.

The authors evaluated patients who underwent orthopaedic surgery distal to the proximal tibial articular surface, including foot/ankle procedures, open reduction of lower-leg fractures, and BTK amputations. They performed propensity score matching to compare 5,286 patients who received any type of chemotherapeutic prophylaxis with the same number who did not, across several key risk categories. The good news is that VTE prophylaxis effectively lowered the risk of symptomatic DVT or PE from 1.9% to 0.7% (odds ratio of 0.38, p <0.001).

Unfortunately (but not surprisingly), this effectiveness came at the price of increased systemic or local bleeding among patients using chemical VTE prophylaxis, with an incidence of 1.0% in the no-prophylaxis group and 2.2% in the prophylaxis group (odds ratio of 2.18, p <0.001). The authors did not assess the incidence of deep infection or hematoma formation, which often accompany increased local bleeding. The low overall incidence of VTE and bleeding did not allow for subgroup analysis according to location of surgery, and aspirin use was not controlled for in their study. In addition, Heijboer et al. used hospital coding data, and the accuracy of the database was not assessed.

The authors recommend that “anticoagulant prophylaxis be reserved only for patient groups who are deemed to be at high risk for VTE,” but we still don’t know precisely who is at high risk among BTK surgery patients. It is my hope that these findings will prompt large, prospective multicenter trials in the foot and ankle community to better determine which types of patients should be exposed to an increased risk of postoperative bleeding complications in order to achieve a clinically important decreased risk of VTE with chemical prophylaxis.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

In My Hands, There’s a Dog Leash

As a journalist covering symposia at the 2019 AAOS Annual Meeting last week, I repeatedly heard the phrase “in my  hands…,” referring to a surgeon’s individual experience with this or that technique. That got me to thinking about a research letter published in the March 6, 2019 issue of JAMA Surgery. This retrospective cross-sectional analysis of emergency department data revealed that the annual number of patients ≥65 years old presenting to US emergency departments with fractures associated with walking leashed dogs more than doubled during 2004 to 2017. Women sustained more than three-quarters of those fractures, and while the hip was the most frequently fractured body part, collectively, the upper extremity was the most frequently fractured region. Slightly more than one-quarter of those patients were admitted to the hospital.

The authors rightly pinpoint the “gravity of this burden”; the hip-fracture data alone are worrisome. And in a related online article by hand and wrist surgeons from Rush University Medical Center (titled “Doggy Danger”), the focus is on the many injuries that the human leash-holding apparatus can sustain. The authors of the JAMA Surgery research letter and the Rush authors offer common-sense advice for all us older dog walkers out there, including:

  • Dog obedience training that teaches Bowser not to pull or lunge while on leash
  • Selection of smaller dogs for older people contemplating acquiring a canine companion
  • Holding the leash in your palm, not wrapping it around your hand
  • Paying attention to where you walk, and being situationally aware (That means not texting while your dog is momentarily sniffing to see who peed on that post.)
  • Selecting footwear that is appropriate for the terrain and environmental conditions during your walk

To these tidbits I would add finding a safe area where your dog can “be a dog” off-leash, preferably with other dogs and people. Socializing is good for both species, and most dog trainers and owners agree that “a tired dog is a good dog.”

The research letter states that a “risk-benefit analysis with respect to dog walking as an exercise alternative is essential,” and the authors do a concise job of quantifying fracture risk and suggesting risk-reduction strategies. The list of benefits from dog walking is too long to itemize here; suffice to say that the advantages run the gamut from physical to mental to spiritual. But let’s be safe and sensible out there. We owe it to our families (dogs included, of course) and to all those overworked orthopaedic trauma surgeons to stay on the sidewalks and in the forests and fields–and out of the ER.

Lloyd Resnick
JBJS Developmental Editor

In THA, Less Blood Loss with Multidose Postop Oral TXA

The recent orthopaedic literature, including a 2017 JBJS study, provides substantial evidence that oral and intravenous tranexamic acid (TXA) are equivalent in their effectiveness at reducing blood loss after total hip arthroplasty (THA)—with oral administration being less expensive and more convenient. But what are the optimal doses and timing of oral TXA in the setting of THA?

The findings of a randomized controlled trial by Wang et al. in the March 6, 2019 issue of JBJS go a long way toward answering that question. The authors randomized 200 patients undergoing primary THA to 1 of 4 groups, with all patients receiving an intraoperative topical dose of 1.0 g of TXA and a single dose of 2.0 g of TXA orally at 2 hours postoperatively. In addition,:

  • Group A received 1.0 g of oral placebo at 3, 9, and 15 hours postoperatively
  • Group B received 1.0 g of oral TXA at 3 hours postoperatively and 1.0 g of placebo at  9 and 15 hours postoperatively
  • Group C received 1.0 g of oral TXA at 3 and 9 hours postoperatively and 1.0 g of placebo at 15 hours postoperatively
  • Group D received 1.0 g of TXA at 3, 9, and 15 hours postoperatively

The mean total blood loss during hospitalization was significantly less in Groups B, C, and D (792, 631, and 553 mL, respectively) than in Group A (984 mL). Groups C and D had lower mean reductions in hemoglobin than did Groups A and B. No significant between-group differences were observed regarding 90-day thromboembolic complications (there were none) or transfusions (there was only 1, in Group A), but the authors said “this study was likely underpowered for establishing meaningful comparisons concerning [those 2] outcomes.”

Although this study documented significantly lower total blood losses in patients who were managed with multiple doses of oral TXA postoperatively, additional studies are required to determine whether the 3-dose regimen is superior to the 2-dose regimen.