In the February 15, 2017 issue of The Journal, Aneja et al. utilize a large administrative database to examine the critical question of venous thromboembolism (VTE) risk as it relates to managing patients with metastatic femoral lesions. The authors found that prophylactic intramedullary (IM) nailing clearly resulted in a higher risk of both pulmonary embolism and deep-vein thrombosis, relative to IM nailing after a pathologic fracture. Conversely, the study found that patients managed with fixation after a pathological fracture had greater need for blood transfusions, higher rates of postoperative urinary tract infections, and a decreased likelihood of being discharged to home.
The VTE findings make complete clinical sense, because when we ream an intact bone, the highly pressurized medullary canal forces coagulation factors into the peripheral circulation. When we ream after a fracture, the pressures are much lower, and neither the coagulation factors nor components of the metastatic lesion are forced into the peripheral circulation as efficiently, although some may partially escape through the fracture site.
One might conclude that we should never consider prophylactic fixation in the case of metastatic disease in long bones, but that would not be a patient-centric position to hold. In my opinion, the decision about whether to prophylactically internally fix an impending pathologic fracture should be based on patient symptoms and consultations with the patient’s oncologist and radiation therapist.
If all of the findings from Aneja et al. are considered, and if the patient’s symptoms are functionally limiting after initiation of appropriate radiation and chemotherapy, prophylactic fixation should be performed, along with vigilantly managed VTE-prevention measures. This study is ideally suited to inform these discussions for optimum patient care.
Marc Swiontkowski, MD
In the February 1, 2017 edition of The Journal, Deren et al. provide an important analysis of muscle mass as it relates to mortality in older patients with an acetabular fracture. Among 99 fracture patients studied retrospectively, 42% had sarcopenia, defined in this study as a skeletal muscle index at the L3 vertebral body of <55.4 cm2/m2 for men and <38.5 cm2/m2 for women.
Deren et al. found that low BMI was associated with sarcopenia and that patients with sarcopenia were significantly more likely than patients without sarcopenia to sustain their skeletal injury from a low-energy mechanism. Sarcopenia was also associated with a higher risk of 1-year mortality, especially when in-hospital deaths were excluded. While the authors note that there’s no consensus definition for clinically diagnosing sarcopenia, they conclude that “sarcopenia based on the skeletal muscle index may be a better predictor of mortality than other commonly used classification
There are important subtextual messages in this study for all physicians who manage geriatric patients. Maintenance of muscle mass by resistance exercise (lifting weights, isometrics, etc.) is of critical importance in limiting fall risk and maintaining good balance and bone density. Dietary considerations are intertwined with exercise in maintaining muscle mass among older patients. Resistance training and cardio exercise help to maintain appetite, and adequate protein intake is of utmost importance. When families and medical teams work together, the risk of sarcopenia can be minimized, resulting in lower rates of falls, fewer low-energy fractures, and less mortality.
Marc Swiontkowski, MD
In the January 18, 2017 issue of JBJS, Krych et al. report on early and mid-term results of the two most common surgical procedures to help patients 55 years old and younger with varus knees and medial compartment osteoarthritis: unicompartmental knee arthroplasty (UKA) and proximal tibial osteotomy (PTO). PTO realigns the knee’s biomechanics by moving the weight-bearing line laterally toward the more normal side of the knee. UKA corrects the biomechanical issue and removes and resurfaces damaged tissue.
In this comparative cohort study of 240 patients between 18 and 55 years old, patients receiving UKA had better functional scores and reached a higher activity level early after surgery. UKA survivorship (defined as avoiding revision to total knee arthroplasty [TKA]) was 94% at an average of 5.8 years, while PTO survivorship was 77% at an average of 7.2 years.
The functional outcomes should come as no surprise, seeing as arthroplasty replaces/denervates the subchondral bone in the medial compartment, while also correcting the alignment issue. A reasonable trauma-related analog to this can be seen with total hip arthroplasty providing generally better functional outcomes for displaced femoral neck fractures than internal fixation because the latter approach does not anatomically restore hip biomechanics. In both those cases, the mechanics of a weight-bearing joint are maintained/improved without relying on bone to heal. In contrast, with PTO and other bone and joint “preservation” approaches, the natural mechanics are altered.
However, I do not think we should extend this argument beyond what these data from Krych et al. provide. The mean length of follow-up in the UKA group was only 5.8 years. We need 20- to 30-year results in that group so we can truly understand the risk of further arthroplasty revision, polyethylene replacement, periprosthetic fracture, etc. I therefore truly hope to see follow-up reporting in a decade on this cohort of patients.
We must also recognize that these patients were selected for a surgical intervention based on their functional demand. The baseline characteristics of both groups suggest that those who had higher loading “habits” received an osteotomy.
Marc Swiontkowski, MD
In the January 4, 2017 issue of The Journal, Swart et al. provide a well-done Markov decision analysis on the cost effectiveness of three treatment options for femoral neck fractures in patients between the age of 40 and 65: open reduction and internal fixation (ORIF), total hip arthroplasty (THA), and hemiarthroplasty. Plugging the best data available from the current orthopaedic literature into their model, the authors estimated the threshold age above which THA would be the superior strategy in this relatively young population.
For patients in this age group, traditional thinking has been to perform ORIF in order to “save” the patient’s native hip and avoid the likelihood of later revision arthroplasty. However, in this analysis THA emerges as a cost-effective option in otherwise healthy patients >54 years old, in patients >47 years old with mild comorbidity, and in patients >44 years old with multiple comorbidities.
On average, both THA and ORIF have similar outcomes across the age range analyzed. But ORIF with successful fracture healing yields slightly better outcomes and considerably lower costs than THA, whereas patients whose fracture does not heal with ORIF have notably worse outcomes than THA patients. This finding supports my personal bias that anatomical reduction and biomechanically sound fixation must be achieved in this younger population with displaced femoral neck fractures. The analysis confirmed that, because of poor functional outcomes with hemiarthroplasty in this population, hemiarthroplasty should not be considered. Poor hemiarthroplasty outcomes are likely related to the mismatch between the metal femoral head and the native acetabular cartilage, leading to fairly rapid loss of the articular cartilage and subsequent need for revision.
This analysis by Swart et al. provides very valuable data to discuss with younger patients and families when engaging in shared decision making about treating an acute femoral neck fracture. In my experience, most patients in this age group prefer to “keep” their own hip whenever possible, which puts the onus on the surgeon to gain anatomic reduction and biomechanically sound fixation with ORIF.
Marc Swiontkowski, MD
“Necessity is the mother of invention.” In recent years, the demand for total hip, total knee, and unicompartmental knee arthroplasty has grown substantially. However, with limited resources and health-care budgets, there is a need to reduce hospital costs. To that end, a number of surgeons have begun to perform these procedures on an outpatient basis.
Indeed, as the demand for joint replacements grows, it will be imperative to improve patient safety and satisfaction while minimizing costs and optimizing the use of health-care resources. In order to accomplish this goal, surgical teams, nursing staff, and physiotherapists will need to work together to discharge patients from the hospital as soon as safely possible, including on the same day as the operation. The development of accelerated clinical pathways featuring a multidisciplinary approach and involving a range of health-care professionals will result in extensive preoperative patient education, early mobilization, and intensive physical therapy.
In the December 2016 issue of JBJS Reviews, Pollock et al. report on a systematic review that was performed to determine the safety and feasibility of outpatient total hip, total knee, and unicompartmental knee arthroplasty. The authors hypothesized that outpatient arthroplasty would be safe and feasible and that there would be similar complication rates, similar readmission and revision rates, similar clinical outcomes, and decreased costs in comparison with the findings associated with the inpatient procedure. The investigators demonstrated that, in selective patients, outpatient total hip, total knee, and unicompartmental knee arthroplasty can be performed safely and effectively.
A major caveat of this well-conducted study, however, is that, like any systematic review, its overall quality is based on the quality of the individual studies that make up the analysis. In this case, the studies included those that lacked sufficient internal validity, sample size, methodological consistency, and standardization of protocols and outcomes. Thus, going forward, there is a need for more rigorous and adequately powered randomized trials to definitively establish the safety, efficacy, and feasibility of outpatient hip and knee arthroplasty.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
We have entered an era where total ankle arthroplasty (TAA) is accepted as a rational approach for patients with degenerative arthritis of the ankle. TAA results have been shown to be an improvement over arthrodesis in some recent comparative trials.
That was not always the case, however. In the 1980s, the orthopaedic community attacked ankle joint replacement with gusto, and numerous prosthetic designs were introduced with great enthusiasm based on short-term cohort studies. Unfortunately, the concept of TAA was all but buried as disappointing longer-term results with those older prosthetic designs appeared in the scientific literature. It took a full decade for new designs to appear and be subjected to longer-term follow-up studies before surgeons could gain ready access to more reliable instrumentation and prostheses. The producers of these implants behaved responsibly in this regard, facilitated by an FDA approval process that had increased in rigor.
In the December 21, 2016 issue of The Journal, Hofmann et al. publish their medium-term results with one prosthetic design that was FDA-approved in 2006. Implant survival among 81 consecutive TAAs was 97.5% at a mean follow-up of 5.2 years. There were only 4 cases of aseptic loosening and no deep infections in the cohort. Total range of motion increased from 35.5° preoperatively to 39.9° postoperatively.
The fact that a high percentage (44%) of ankles underwent a concomitant procedure at the time of TAA attests to the need for careful preoperative planning for alignment of the ankle joint and the need for thorough assessment of the hindfoot. The fact that a substantial percentage (21%) of ankles underwent another procedure after the TAA attests to the need for thoughtful benefit-risk conversations with patients prior to TAA.
I think the TAA concept and procedure are here to stay, but we still have much work to do in fine-tuning prosthetic designs and instrumentation and enhancing surgeon education for more reliable outcomes.
Marc Swiontkowski, MD
In the past several years, the orthopaedic community has become highly engaged in improving the follow-up management of patients presenting with fragility fractures. We have realized that orthopaedic surgeons are central to the ongoing health and welfare of these patients and that the episode of care surrounding a fragility fracture represents a unique opportunity to get patients’ attention. Using programs such as the AOA’s “Own the Bone” registry, increasing numbers of orthopaedic practices and care centers are leading efforts to deliver evidenced-based care to fragility-fracture patients.
In the November 16, 2016 edition of The Journal, Aspenberg et al. carefully examine the impact of the anabolic agent teriparatide versus the bisphosphonate risedronate on the 26-week outcomes of more than 170 randomized patients (mean age 77 ±8 years) who were treated surgically for a low-trauma hip fracture. This investigation is timely and appropriate because our systems of care are evolving so that increasing numbers of patients are receiving pharmacologic intervention for low bone density both before and after a fragility fracture.
The secondary outcomes of the timed up and go (TUG) test and post-TUG test pain were better in the teriparatide group, but there were no differences in radiographic fracture healing or patient-reported health status.
Although this study was designed primarily to measure the effects of the two drugs on spinal bone mineral density at 78 weeks, these secondary-outcome findings confirm the value of initiating pharmacologic intervention early on after a fragility fracture, whether it’s a bisphosphonate or anabolic agent. The orthopaedic community needs to continue leading multipronged efforts to deal with the public health issues of osteoporosis and fragility fractures.
Click here for additional OrthoBuzz posts related to osteoporosis and fragility fractures.
Marc Swiontkowski, MD
The evolution of more rational educational programs and other societal changes point to a future where an increasing number of orthopaedic surgeons will be female. Thankfully, we have made gains in adjusting the medical community’s perspective on careers in orthopaedic surgery. No longer are we perceived to be “stronger than a mule and twice as smart” or merely “buckles and braces men.” Evolving interventional techniques that rarely require brute force have also helped change this view.
At the same time, with the rapidly increasing need for musculoskeletal care as the population ages, we need every orthopaedic practitioner—male and female—to remain as healthy and active as possible. Epidemiologic studies of surgeon health have revealed real concerns for neck and back degenerative changes and cancer risk.
In the November 2, 2016 edition of The Journal, Valone et al. tackle the issue of exposure of the female breast to intraoperative radiation. In a nifty study incorporating C-arm fluoroscopy and an anthropomorphic torso phantom equipped with breast attachments and dosimeters, the authors found that:
- The median dose-equivalent rate of scatter radiation to the breast’s upper outer quadrant (UOQ) was higher than that to the lower inner quadrant.
- C-arm cross-table lateral projection was associated with higher breast radiation exposure than anteroposterior projection.
- Size, fit, and breast coverage of lead protection matter.
The findings should prompt redesign of protective aprons and vests to more effectively cover the breast and axilla. We could also use more well-designed longitudinal studies to identify the risk factors for neck, back, and shoulder injury as well as gain a better understanding of the real risk of surgeon exposure to intraoperative radiation.
Annual occupational radiation dose limits to the breast have not yet been established. But in the meantime, Valone et al. recommend distancing the axilla from the C-arm and placing the X-ray source beneath the operating table or on the contralateral side to reduce radiation exposure to the UOQ of the breast.
Marc Swiontkowski, MD
The practice of orthopaedic surgery is moving fairly rapidly to the outpatient environment. Advances in less invasive surgical procedures, regional anesthesia, and postoperative pain management have provided the foundation for this transition. The migration to outpatient surgery centers enables surgeons to use surgical teams more focused on orthopaedic technology and practice parameters. The concern that arises in everyone’s mind, though, is the issue of safety.
In the October 19, 2016 issue of JBJS, Qin et al. analyzed the NSQIP database and found that the outpatient surgical treatment of patients with a closed ankle fracture and minimal comorbidities resulted in lower risk of pneumonia and no difference in surgical morbidity, reoperations, and readmissions when compared with inpatient surgery.
The NSQIP dataset is voluntary and, as with any database, confounding variables are unavoidable. But these authors used propensity score matching and Bonferroni correction to minimize selection bias and manage multiple comparisons.
The study excluded emergency cases, cases with preoperative sepsis, and cases of open ankle fracture, and I can still foresee that patients with more severe fracture patterns, soft tissue compromise, and unstable medical comorbidities would be better off treated as inpatients. Nevertheless, it is reassuring that this study found no differences in complication or readmission rates. These findings reinforce the movement of orthopaedic surgical practice to the outpatient setting, and in my experience that movement is wholly welcomed by patients and their families.
Marc Swiontkowski, MD