Safe Retractor Placement during Direct Anterior THA

One of my residency mentors always stressed that orthopaedic surgeons should be “masters of musculoskeletal anatomy.” During his first lecture each July, he would grill the junior residents on muscle origins and insertions, along with innervations. Knowing safe surgical planes helps us avoid complications from neural or vascular injury and increases the likelihood of a successful orthopaedic procedure. With the increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), it is crucial that orthopaedists understand the anatomical implications of that technique.

One key to a successful DAA hip replacement is adequate visualization, which is aided by retractors. However, malpositioned retractors can cause femoral nerve palsy, a potentially serious neurological complication that can delay postoperative rehabilitation. In the January 15, 2020 issue of The Journal, Yoshino et al. report on a cadaveric study that quantifies the distance between the femoral nerve and the acetabular rim at varying points along the rim. Knowing these precise distances could help surgeons make safer decisions about where—and where not—to place retractors.

The authors dissected 84 cadaveric hips from 44 formalin-embalmed cadavers and measured the distance from the femoral nerve to various points along the acetabular rim by using a reference line drawn from the anterior superior iliac spine (ASIS) to the center of the acetabulum. They found the femoral nerve was closest to the rim (only 16.6 mm away) at the 90° point.

In addition, at 90°, the thickness of the iliopsoas muscle and the femoral length (a probable proxy for size of the patient) were positively associated with increased distance to the nerve. Other anatomic factors such as inguinal ligament length, femoral head diameter, and thickness of the capsule were not associated with the nerve-rim distance.

The degree nomenclature used by Yoshino et al. can be correlated to a clock-face representation of the acetabulum, with the 60° point at the 3 o’clock (anterior) position; the 30° point represents a relatively safe  location for placement of the anterior inferior iliac spine retractor (see Figure above).

This important anatomic study can help us improve our mastery of musculoskeletal anatomy—and avoid, if possible, placement of retractors at 90° relative to a line drawn from the ASIS to the center of the acetabulum.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Elite Reviewer Spotlight: Andrew Kurmis

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Professor Andrew Kurmis

Affiliation:

Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia

Years in practice: Less than 10 years

How did you begin reviewing for other journals and for JBJS in particular?

I received an invitation from an editor, and I was recommended to contact JBJS with regard to potentially reviewing by an esteemed colleague.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Be sensible with your reviewer workload. A well-done review usually requires good time commitment and effort – this is sometimes hard to achieve if you have too many demands on your plate at the time.

Aside from orthopaedic manuscripts, what have you been reading lately?

I was recently invited to co-author a review article for one of the anaesthetic journals – I have been busily reading anaesthetic manuscripts!

Learn more about the JBJS Elite Reviewers program.

Strong Case for Outpatient Fracture Surgery

Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.

Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.

Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.

On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.

It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: Peter Passias

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Peter G. Passias, M.D., MSc.

Affiliation:

NYU Medical Center / NY Spine Institute

NY, NY. U.S.A.

Years in practice: 9

How did you begin reviewing for other journals and for JBJS in particular?

I first started reviewing for several years as an invited reviewer for several spine journals including Spine, Neurosurgery, Journal of Biomechanics, Journal of Neurosurgery, The Spine Journal, among others. After years of service I was graced with the opportunity to review for JBJS with an invite from the Editor Andrew Schoenfeld, M.D., who is a great thought leader in our field.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

My opinion is that it is not about just coming up with the appropriate response as to whether a rejection, revision or acceptance is indicated. It is primarily about providing a thorough structured review of the hypothesis, study design, and execution and presentation of the study being reviewed, based upon what we consider the acceptable recommendations for a bias-free supported conclusion in a manuscript. That being said, many of the manuscripts fall under the category of revisable and potentially acceptable. In these circumstances, it is imperative to provide the authors with a structured point by point recommendation of how the study at hand can be improved to an acceptable version.

Aside from orthopaedic manuscripts, what have you been reading lately?

I always make it a point to review top clinically relevant articles, on a weekly basis, in the field of spinal research from top orthopaedic, neurosurgery, and biomechanical journals in terms of impact. Following that, I always peruse NEJM, JAMA, and LANCET for any surgical related articles that have met criteria for acceptance. Lastly, I stay abreast in the field of spine related health economics by reading several business-oriented spine publications, including Beckers among others.

Learn more about the JBJS Elite Reviewers program.

Curb Your Enthusiasm about Stem Cells for Knee OA

Mark Miller, MD is a professor of orthopaedic surgery at the University of Virginia, founder and co-director of the Miller Review Courses, and former deputy editor for sports medicine at JBJS. In a piece he authored recently for The Conversation, Dr. Miller labeled stem-cell treatments for knee osteoarthritis (OA) “unproven, expensive, and potentially dangerous.”

About 2 years ago, Dr. Miller himself underwent bilateral knee replacements for severe knee arthritis. He understands why patients may fall prey to misleading marketing hype that claims stem cell treatments can help people postpone or entirely avoid knee replacement. (See related OrthoBuzz post.) “My mission,” he writes, is to “try to keep the enthusiasm regarding new cutting-edge options in check,” adding that “the excitement about stem cells has outpaced the science,” especially when it comes to knee OA.

Although stem cell injections have been promoted as a way to regenerate cartilage in arthritic joints, Dr. Miller echoes the American Association of Hip and Knee Surgeons when he says that “there are no proven…therapies that can delay or reverse the progressive joint destruction that occurs with osteoarthritis.” Moreover, the do-no-harm part of the Hippocratic oath requires doctors to give their patients “a clear picture of the potential benefits and side effects of their treatment options,” writes Dr. Miller, who cited a December 20, 2018 New York Times article describing 12 patients who were hospitalized for serious infections after receiving stem cell injections into their knees, shoulders, or spines.

For their part, Dr. Miller says patients should employ the “buyer beware” concept because stem cell therapy for osteoarthritis is not only unproven but also expensive—and usually not covered by medical insurance. The best approach to knee OA, says Dr. Miller, is what is nowadays called shared decision making: “Physicians need to work closely with patients to help them understand their options and which choice may be best for them.”

Elite Reviewer Spotlight: Shivi Duggal

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Shivi Duggal, MD, MBA, MPH

Affiliation: SUNY Albany School of Public Health, Rensselaer, NY

Years in practice: I am a recent medical school graduate.  I took some time after my medical school graduation to pursue and complete my public health degree.

How did you begin reviewing for other journals and for JBJS in particular?

I contacted the editorial department and applied.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

The best advise I can provide to reviewers is to make sure once a week time is set aside to perform reviews, so you can provide ideal reviews in an efficient timely manner.   This will not only benefit you as a reviewer, but also benefit the journal and those submitting manuscript to the journal. 

Aside from orthopaedic manuscripts, what have you been reading lately?

Varies.

Learn more about the JBJS Elite Reviewers program.

What’s Really Important to You?

The two most recent JBJS “What’s Important” articles (“Learning Names” by J. Lawrence Marsh in the December 4, 2019 issue and “Not Becoming a Robot” by Ramon B. Gustilo in the January 2, 2020 issue) typify the variety of topics and individuality these personal essays are known for.

Dr. Marsh’s piece is about leadership, with the focal point being golf great Arnold Palmer. “I will never forget that he knew each of our names…and wanted to know our stories,” Dr. Marsh writes, recalling the day he and 4 friends played 9 holes with Arnie during a charity golf tournament. “We had the impression that he would not want to be anyplace else in the world other than playing golf with us,…a foursome of nobodies.” From that day on, Dr. Marsh has practiced leadership that entails much more than strategic thinking and motivational rhetoric: “With a smile, a pleasantry, a handshake, or an offer to help, a leader can leave a positive impression,” he writes.

Dr. Gustilo’s “What’s Important” essay is clinically focused on orthopaedics, but he too emphasizes the human component. Echoing the experiences and message of an earlier “What’s Important” author, Jack W. Crosland, Dr. Gustilo laments the “industrialization of medicine.” Citing one of several examples, he writes that the overuse of advanced imaging such as CT and MRI “leads to the deterioration of the practice of history-taking and physical examination of the patient.”

What’s really important to you? If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an artic le type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning in the title field.

Because they are personal in nature, “What’s Important” submissions are not subject to the usual stringent JBJS peer-review process. Instead, they are reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

Elite Reviewer Spotlight: Iftach Hetsroni

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Iftach Hetsroni

Affiliation: Meir Medical Center, Kfar Saba, Israel & Sackler Faculty of Medicine, Tel Aviv University, Israel

Years in practice: I have been a Senior Orthopedic Surgeon since 2007

How did you begin reviewing for other journals and for JBJS in particular?

Reviewing was natural and very fulfilling. I was asked by several journals; I did not always know exactly how they found my details and reached for me, but I rarely refused. I did not know at the beginning how crucial and enjoyable this would be for my professional career but today without any doubt reviewing for top journals is a very essential part of my work, improves my writing skills and my knowledge in the field and makes my life more fulfilling as a clinician and as a researcher.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Decide quickly if you are interested in reviewing what you have been asked to, then respond. There is no point in waiting to respond. The review as a top priority. Enjoy it and look for the details. Is this contributing valuable information? Does it have the potential to change anything in the field, and is it conducted properly?

Aside from orthopaedic manuscripts, what have you been reading lately?

I love reading books of many kinds, novels and others.

Learn more about the JBJS Elite Reviewers program.

Revisiting INR Targets Prior to THA

In March 2019, OrthoBuzz covered a JBJS study by Rudasill et al. that found a progressively increasing risk of bleeding requiring transfusion among total knee arthroplasty (TKA) patients who had a preoperative International Normalized Ratio (INR) >1. (INR is a standardized measure of how long it takes blood to clot—the higher the number, the longer the clotting time.) These authors also found a significantly increased risk of infection in TKA patients with INR >1.5. and an increased risk of mortality within 30 days of surgery among those with an INR >1.25 to 1.5.

In the January 2, 2020 issue of JBJS, the same team of researchers report findings from a similarly designed NSQIP-based study of patients undergoing total hip arthroplasty (THA). The authors evaluated data from >17,500 patients who underwent a primary THA between 2005 and 2016 and who also had an INR value documented within 2 days prior to joint replacement. Rudasill et al. stratified these patients into 4 groups based on preoperative INRs: ≤1, >1 to <1.25, 1.25 to <1.5, and ≥1.5).

After adjustment, the authors found a significant, independent effect between increased preoperative INR and increased bleeding requiring transfusion and mortality. Specifically, bleeding risk became evident at INR ≥1.25, and patients with INR ≥1.5 were at a significantly increased risk of mortality. The length of hospital stay also increased significantly as INR class increased.

The authors suggest that “current INR targeting [INR <1.5 for elective orthopaedic surgery] may not be strict enough to minimize adverse outcomes for patients undergoing primary total hip arthroplasty.” While admitting that these findings are not likely to change the day-to-day practice of orthopaedic surgeons, the authors say they “may influence preoperative risk stratification for those patients with elevated INR.”

More Data on Managing Distal Radial Fractures in Old Patients

Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.

In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.

At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.

Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

References

  1. Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
  2. Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.

Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures: