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Strengthening Our Residency Programs through Robust Research

Residency training is an essential pipeline to keeping the field of orthopaedics strong. As I tell the surgeons in my department, we should always be looking for our replacement. Who is going to carry the flag of orthopaedics after our time has passed?

Research related to education and training helps guide us. Continuing a collaboration between the American Orthopaedic Association’s (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the top abstracts from research presented at the 2019 CORD Summer Conference are now available in an article by Weistroffer and Patt on behalf of the CORD/Academics Committee.

Ten studies are featured, with a number looking at aspects of resident screening and selection. For instance, Pacana et al. evaluated use of the standardized letter of recommendation (SLOR) form; while widely adopted, it may not be a cure-all in evaluating applicants, as most applicants were “highly ranked” or “ranked to match.” Work by Secrist et al. suggests that 59 is the number of programs that medical students should target in order to obtain 12 residency interviews (with previous work showing that the average matched applicant attends 11.5 interviews). Alpha Omega Alpha status was the strongest determinant of an applicant’s interview yield. Crawford et al. surveyed residency applicants to find out which characteristics they felt were important to success in an orthopaedic residency. Hard work, compassion, and honesty made the top-10 list each year.

The importance of diversity within orthopaedics is also echoed in the included research. It is well documented that orthopaedic surgery falls far behind other specialties in this area. Among topics explored: potential differences in descriptive terms used in letters of recommendation for male and female candidates, and perceptions of pregnancy and parenthood during residency. Illustrating the importance of exposure and access to role models in orthopaedics, Samora and Cannada found that 80% of female medical students who received a scholarship to attend the Ruth Jackson Orthopaedic Society/AAOS annual meeting eventually pursued a career in orthopaedic surgery. I agree with the authors, who stated, “We must work on diversifying our field and providing opportunities for women and underrepresented minorities to consider a career in orthopaedics.”

I know we will continue to make positive change as a profession. Moreover, I am convinced that the future of orthopaedics is strong, with many with top-notch candidates ready and able to help shape our path.

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

WALANT Surgery Works for Ankle Fractures

OrthoBuzz previously covered WALANT (wide awake, local anesthesia, no tourniquet) surgery, and we very recently featured a JBJS study about treating ankle fractures in a limited-resource environment. These 2 concepts unite in a JBJS study by Tahir et al., which reports on WALANT surgery for ankle fractures in Pakistan.

WALANT surgery has enjoyed increasingly broad dissemination throughout the world since its popularization by Canadian hand surgeon Don Lalonde. Considering its origins, WALANT has been adopted most enthusiastically by the hand-surgery community, but it has been applied successfully to other anatomic regions. WALANT principles are particularly relevant in settings where anesthetic resources and expertise may be limited, such as hospitals where monitoring equipment that helps ensure safe general anesthesia is not readily available.

Tahir et al. used WALANT during open reduction/internal fixation (ORIF) in 58 patients (average age of 47 years) with a distal fibula fracture; 62% of those fractures were OTA-classified as 44C2. Among the excellent results in this cohort were a mean intraoperative VAS pain score of 1.24 and a mean operative time of <1 hour. These findings point to the potential for safely using WALANT techniques during ORIF of other fracture types.

The authors emphasize, however, that “each patient should be individually assessed by the operating surgeon,” not only for injury characteristics that contraindicate WALANT, such as substantial swelling, but also for anxiety and psychological disorders. Consequently, Tahir et al. recommend that surgeons undertaking WALANT procedures have a backup anesthetist available so they can convert to general anesthesia in cases of patient anxiety.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Cost-Effectiveness of Endoscopic vs Open Carpal Tunnel Release

Carpal tunnel release (CTR) is one of the most common upper-extremity procedures, with excellent outcomes and lasting benefits. When comparing the surgical options of open versus endoscopic CTR, studies have noted higher rates of transient nerve injury but lower risk of wound problems after endoscopic release. Long-term clinical outcomes appear to be similar between the 2 techniques.

What about the associated costs? This is a multidimensional question of particular relevance given the high economic impact of carpal tunnel syndrome, a leading cause of lost work time. Barnes et al. shed new light on the cost-effectiveness of endoscopic versus open CTR in a recent JBJS report, offering a look from societal and payer perspectives. In this cost-effectiveness analysis, the authors developed a Markov model to evaluate unilateral open versus endoscopic CTR in an office setting with local anesthesia and an operating room (OR) setting under monitored anesthesia care. Comprehensive outcomes data from published meta-analyses helped to inform the modeling, while the costs of CTR, performed from 2012 to 2016, were obtained from a large Medicare claims database.

The authors note that, with complications rates being relatively balanced between the 2 techniques, and differences in quality-adjusted life-years being small (<1 quality-adjusted life-day), “procedural and lost-productivity costs primarily drove the results.” (The model assumed 8.21 fewer days of missed work after endoscopic CTR.) Health-care costs are larger for endoscopic CTR, but “the impact of lost productivity was important.” For instance, endoscopic release in the OR setting becomes cost-effective if the patient’s expected return to work is even 1.2 days earlier than that following open CTR in the OR. However, because of the lower costs of performing open CTR in the office setting, endoscopic CTR in the OR is cost-effective only if the expected return to work is at least 3.9 days earlier than that following open CTR in the office.

Overall, the authors concluded that, from a payer perspective, endoscopic CTR is more expensive than open CTR and only becomes truly cost-effective if performed in an office setting under local anesthesia. However, from a societal perspective, earlier return to work may help tip the scales in favor of endoscopic release. The authors caution that additional research is needed to confirm their findings based on the latest surgical techniques and return-to-work protocols.

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

Click here for a JBJS Clinical Summary on the treatment of carpal tunnel syndrome.

Sustainable Trauma Care in Low-Resource Settings: How Can We Help?

Orthopaedic colleagues who live and practice in low-resource areas around the world have clearly voiced that they want support from better-resourced partners. But such efforts must be sustainable, a key point emphasized by Woolley et al. in their thought-provoking 2019 JBJS “What’s Important” essay regarding orthopaedic care in Haiti. In contrast to “medical missions” offering short-term assistance for a small number of patients, longer-term systemwide gains come from partnerships focused on education and training that acknowledge the central role of local orthopaedic practitioners in addressing the ongoing needs of their patients.

Along those lines, Agarwal-Harding et al. describe a 3-phase pathway for improving ankle-fracture management in sub-Saharan Malawi in their recent JBJS report. In the first 2 phases, the local knowledge base and treatment strategies were assessed. (Greater than 90% of orthopaedic trauma care in the country is provided by nonphysician “clinical officers,” and most ankle-fracture management in Malawi is nonoperative because there is only about 1 orthopaedic surgeon per 1.9 million Malawians). A team of Malawian and US faculty then designed and implemented an education course that reviewed ankle anatomy, fracture classification, and evidence-based treatment guidelines. From that arose standardized protocols to improve fracture-care quality and safety in the face of limited resources.

While these protocols were unique to the Malawian context, I am convinced that similar interventions can be adapted for other low-resource environments—as long as local clinicians are part of the process. With such a flexible and sustainable program in place, efforts can then be directed toward the advancement of surgical skills and development of cost-effective supply chains. We should all support such efforts worldwide, recognizing that the burden of musculoskeletal trauma is a public health issue warranting collaborative solutions with lasting impact.

Marc Swiontkowski, MD
JBJS Editor-in-Chief


Click here for a related OrthoBuzz post about trauma care in Malawi.

Day-of-Surgery Post-op Talks with Patients Worth the Effort

Personal communication goes a long way in establishing and cementing surgeon-patient relationships. I learned years ago that something as simple as giving patients my email address diminished their fear and anxiety because it gave them direct access to me. Now, due largely to the recent pandemic, more numerous and sophisticated forms of “telemedicine” have come to the forefront of health-care delivery.

In the February 3, 2020 issue of The Journal, Kingery et al. report results from a randomized controlled trial investigating whether brief day-of-surgery communications between surgeons and patients who underwent an outpatient sports-medicine procedure affected patient satisfaction scores. To find out, the researchers randomized 3 surgeons into 1 of 3 patient-communication modalities:

  1. No contact (standard of care)
  2. Phone call the evening after surgery
  3. Video call the evening after surgery

Satisfaction among the 250 participating patients was assessed at the first face-to-face postoperative visit using the standardized S-CAHPS questionnaire, which evaluates patient experiences before, during, and after an outpatient surgery. Patients also completed a 9-item questionnaire specifically designed for this study. The authors focused on the rate of “top-box” responses (the highest rating possible) in each of the 3 groups group.

Kingery et al. found that day-of-surgery postoperative communication between patients and surgeons, either by video or phone, significantly improved S-CAHPS top-box response rates relative to the no-contact group. Specifically, phone calls were associated with a 16.1 percentage point increase in the top-box response rate, while video calls were associated with a 17.8 percentage point increase. The authors also found that patients contacted by video or phone were more likely to recommend their surgeon and felt more informed than those who were not contacted.

Although the authors did not record the content or duration of the conversations in the 2 contact groups, these data strongly suggest that patients welcome day-of-surgery communication—and that such encounters improve patient satisfaction. I therefore think we all should consider leveraging technology, especially that which has arisen from the COVID pandemic, to help give our patients a better overall health-care experience. A few non-reimbursable minutes at the end of the day could have lasting, positive effects on both patients and us.

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

Micromotion Followed by Rigid Fixation Boosts Fracture Healing

Mechanical factors undoubtedly play a role in the rate and quality of fracture healing. For example, the seminal work on fracture strain by the late Stephan Perren, MD helped us understand that the larger the overall fracture area, the lower the fracture strain—and that less strain encourages fracture union.

But with the variety of fracture planes and orientations, different energies imparted to produce the fracture, and multiple patient factors such as bone density, the best approaches by which to positively influence fracture-healing mechanics are still being investigated. We do know that motion mechanics come into play for nonsurgically stabilized fractures in our patients.

In the February 3, 2021 issue of The Journal, Glatt et al. provide more data on the role of micromotion in fracture healing. The authors created a 2-mm transverse tibial osteotomy in 18 goats and then used an external fixator to achieve static, rigid fixation in 6 of the osteotomized tibiae. Six other tibiae were treated with a fixator that allowed 2 mm of controlled axial micromotion for the 8-week duration of the experiment. (This so-called dynamization technique was championed more than 30 years ago by Fred Behrens, MD, who established that inducing micromotion helps stimulate maturation of fracture callus.) The remaining 6 tibiae were initially treated with dynamization, followed by rigid fixation during weeks 4 through 8—a technique known as reverse dynamization. The experimental groups simulated 3 different versions of cast or brace immobilization without surgery.

Using radiographs, micro-CT data, and torsion testing, the investigators found that, after 8 weeks, bones in the reverse-dynamization group were significantly stronger and showed more characteristics of intact, contralateral tibiae than the treated bones in the other 2 groups. I agree with the authors’ conclusion that their results “may have important consequences regarding our understanding of the optimum fixation stability necessary to maximize the regenerative capacity of bone-healing clinically.” With this experiment, Glatt et al. have added another important piece to the puzzle that Drs. Perren and Behrens started solving many years ago.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

A Closer Look at Impingement in Ceramic-on-Ceramic THA

Total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) bearings has become popular, especially in younger patients, largely because of the material’s durability. However, CoC bearings are susceptible to catastrophic failure through fracture. Although the definitive mechanistic pathway for ceramic fracture has not been elucidated, one of the proposed mechanisms is impingement between the ceramic acetabular liner and the metal neck of the femoral stem. In the January 20, 2021 issue of The Journal, Lee et al. take an illuminating radiographic dive into the patterns of impingement in CoC THA.

The authors analyzed 244 cases of CoC THAs that had ≥15 years of radiographic follow-up. They found impingement-related notches at 77 sites in 57 (23.4%) of the cases. The notches were seen either on the neck (28 cases) or on the shoulder (29 cases) of the stem. In 8 cases, notches were found in multiple locations.

All of the neck notches were found when either a medium-neck or long-neck head was used. Shoulder notches were found on the stem only when a short-neck head was used. Lee et al. observed that the use of medium-neck or long-neck heads prevents the ceramic liner from contacting the stem shoulder because the liner impinges on the neck first. The authors also noted that the mean cup inclination was significantly lower in the cases with notched stems compared to stems without notches (36.9° vs 39.8°), and that mean anteversion was higher in the cases with notches (19.9° vs 17.3°).

We have known that impingement can occur between the ceramic liner and metal stem in CoC THA, but this study suggests that it may happen in a significant proportion of patients, both along the neck and shoulder of the stem. Manufacturers should consider these findings when designing implants, and patients and surgeons considering CoC implants may want to avoid short-neck heads, if possible. Also, because impingement-related stem notching appears to occur more frequently with lower cup inclination and higher anteversion, surgical technique remains vitally important in these cases, independent of implant design and selection.

Finally, we should note that the patients in this study were young (mean age of 43 years) and Asian. Asian culture and lifestyle include frequent squatting and sitting cross-legged, which Lee et al. say “induces more impingement between the stem and liner.”

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

Halt Bisphosphonates in Patients with an Atypical Femoral Fracture

Osteoporosis is the major contributor to the increasing incidence of fragility fractures associated with low-energy falls. The other contributor is the populous baby-boomer generation that is entering its final decades of life. Our orthopaedic community has made some progress in “owning the bone” to prevent fragility fractures. For example, we have gotten better at identifying a first fragility fracture as a major risk for a subsequent fracture; we more frequently initiate medical treatment for osteoporosis, and we are more inclined to refer patients with a first fragility fracture to a fracture liaison service, if one exists (see related OrthoBuzz posts).

However, orthopaedic physicians treating patients with fragility fractures need to remember that osteoporosis-treatment complications are also within our scope of responsibility. In the January 20, 2021 issue of The Journal, Lee et al. retrospectively analyzed 53 patients (all women, with an average age of 72 years) who had a complete atypical femoral fracture (AFF), a phenomenon primarily related to bisphosphonate treatment for osteoporosis. More than 37% of these patients were given bisphosphonates after their first AFF, and among those 53 patients who went on to show radiographic progression toward a second AFF in the contralateral femur, 61% used bisphosphonates after surgery for the first AFF.

The most shocking aspect of the findings by Lee et al. is the unacceptably high percentage of patients who remained on bisphosphonate therapy after the initial AFF. I wholeheartedly agree with Anna Miller, MD, who writes in her Commentary on this study that “an atypical stress fracture while on bisphosphonates should be considered a failure of bisphosphonate treatment, and that therapy should be stopped immediately.” If there is ongoing osteoporosis in such cases, the orthopaedic surgeon should consider prescribing an anabolic drug such as teraparatide or abaloparatide–and should communicate with the patient’s endocrinologist or other physician who might still be prescribing bisphosphonates.

In my opinion, we have to improve more quickly on both of these clinical issues–secondary fragility fracture prevention and treatment of bisphosphonate-therapy complications–because the population dynamics in the US and worldwide are evolving rapidly.

Click here to view a 2-minute video summary of this study’s design and findings.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Same-Patient Trial Design Measures Incremental Improvements in TKA Outcomes

The clinical and functional outcomes after total knee arthroplasty (TKA) are generally very favorable. The 15% to 20% of subpar patient-reported outcomes are usually related to persistent pain. Orthopaedic researchers have exhaustively investigated patient factors and technical considerations to address dissatisfaction in this minority population of TKA patients.

Meanwhile, the orthopaedic community has focused on prosthetic design in its attempts to incrementally improve outcomes for the 80% to 85% of generally satisfied TKA patients. Clearly documenting those incremental improvements often requires elegant study design. That’s what we see in the January 6, 2021 issue of The Journal, where Kim et al. report findings from a randomized trial in which 2 different knee-implant designs were compared in the same patients after primary simultaneous bilateral TKA.

Each of the 50 patients (49 of them women) received a posterior-stabilized design in 1 knee and an ultracongruent prosthesis in the other. Kim et al. selected the Forgotten Joint Score (FJS) as the primary outcome. The FJS is a 12-item questionnaire that assesses patient awareness of the artificial joint during daily activities. At 2 years, the researchers found no between-knee differences in FJS. The ultracongruent knees showed more anteroposterior laxity and less femoral rollback than the posterior-stabilized knees, but there were, again, no between-group differences in following measures:

  • Range of motion
  • Knee Society and WOMAC scores
  • Side Preference and patient satisfaction

The ultracongruent advancement in prosthetic design does not appear to offer clinically important advantages over the posterior-stabilized design. But if additional TKA patients can be recruited into studies using clever and effective experimental designs like this one, the future is bright for more robust assessments of the incremental impact of prosthetic design on functional and clinical outcomes.

Click here to view an Infographic summarizing this study.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Bone-Preserving Stems in THA – Do They Work?

Total hip arthroplasty (THA) is a tried-and-true treatment for debilitating hip osteoarthritis. But as the number of patients undergoing THA continues to rise, so does the incidence of periprosthetic femoral fractures and the need for revision surgery. The increasing burden of periprosthetic fractures has led to the development of shorter-stemmed femoral components that theoretically preserve bone, decrease fracture risk, and make revision surgery easier if it is required. In the January 6, 2021 issue of The Journal, Slullitel et al. report on a randomized controlled trial that determined whether bone loss differed between patients who received a conventional stem and those who received a short, bone-preserving stem over 2 years following THA.

Forty-six patients received the short, proximally porous-coated stem (Depuy Synthes Tri-Lock bone-preservation stem), and 40 received the conventional stem (Depuy Synthes collarless Corail stem). The primary outcome–bone mineral density (BMD)–was analyzed at 12, 26, 52, and 104 weeks after surgery with dual x-ray absorptiometry region-free analysis (DXA-RFA), which revealed pixel-level resolution of BMD at the bone-implant interface.

Immediately after surgery, researchers found a similar amount of bone loss in both groups in the calcar region and the cancellous portion of the distal greater trochanter. But at all other subsequent time points, bone loss was significantly greater in patients with the bone-preserving stem (analysis of variance [ANOVA] p < 0.0001). In addition, over the full study period the small areas of bone gain that the researchers found were statistically greater in the conventional-stem group than in the Tri-Lock group. Notably, patient-reported outcomes and adverse events did not differ between the 2 groups at the 2-year follow-up.

These early results cast a shadow of doubt over whether a stem that is marketed to preserve bone actually accomplishes that objective. However, 2 years is a very short follow-up when looking at the lifetime of a hip arthroplasty, and the clinical implications of these findings will become clearer with longer-duration analysis.

Click here to read a JBJS Clinical Summary titled “Short-Stem Femoral Components in THA” by Tad Mabry, MD.

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