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Clavicle Fracture Research: Enough Already?

Orthopaedic surgeons and their staffs are aware of the paradigm shift that has taken place in the last 10 to 15 years regarding the treatment of clavicle fractures. Interest in the outcome differences between surgical and nonsurgical treatment has grown substantially since the 2007 Canadian Orthopaedic Trauma Society publication in JBJS showed that, relative to nonoperative treatment, plate fixation of displaced midshaft clavicle fractures resulted in improved functional outcomes and fewer malunions in active adult patients. Since that time, The Journal alone has published 14 articles related to management of clavicle fractures. In addition, the orthopaedic literature contains a number of well-conducted meta-analyses on the topic, comparing both nonoperative and surgical treatment as well as different methods of surgical fixation.

So, with all this evidence, why have we published the randomized controlled trial on this topic by King et al. in the April 3, 2019 issue of The Journal? Partly because the authors build upon our knowledge by comparing a relatively new fixation device (a flexible intramedullary locked nail) to a more standard treatment (an anatomically contoured plate). These plate and nail devices are very different from one another in terms of mechanics and surgical technique, and the flexible nail used in this study is much different than the rigid, straight nails or pins that have been used in the past.

A union rate of 100% was observed in both groups, but the authors found that the flexible nail was significantly faster in terms of operative time. (A single surgeon experienced with both devices performed all 72 surgeries.) They also found that the DASH scores between the groups were similar until the 12 month follow-up, at which point the flexible intramedullary nail group had statistically better scores. The authors concede, however, that the 12-month DASH-score difference “might not be clinically relevant.”

There is one other reason why we deemed this article important: The flexible intramedullary device used in this study is substantially more expensive than prior fixation devices that have been shown to effectively treat clavicular fractures. King et al. did not compare device costs, but whenever we study a device that adds to the total cost of care we should attempt to prove that it adds enough patient benefit to warrant the added expense. As the authors conclude, both devices evaluated in this study appear to be effective at treating displaced/shortened clavicular fractures, and there are a number of other factors that both the surgeon and patient should consider (such as surgeon skill and experience and cosmetic results) when deciding which treatment to use.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

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

A Four-Legged Step Toward Preventing Elbow Contractures

Up to 50% of patients who sustain an elbow injury subsequently develop some type of contracture, making elbow contracture following trauma a common and vexing clinical scenario. While we do not completely understand the molecular basis or structural mechanisms underlying these contractures, we do know that active range-of-motion (ROM) exercises and gentle stretching are often helpful, whereas prolonged immobilization and forceful passive ROM exercises are often, if not always, detrimental.

In the March 6, 2019 issue of The Journal, Dunham and colleagues document with a rat model a better understanding about which specific tissues around the elbow account for this condition. They performed a surgical procedure on rat elbows to simulate a dislocation and then immobilized the injured extremity for 6 weeks. After the authors obtained ROM measurements at that point, some of the rats were allowed an additional 3 or 6 weeks of free active motion before a postmortem surgical dissection was performed to determine which soft tissues were most responsible for the subsequent contracture.

While the authors hypothesized that all soft tissues (muscles/tendons, anterior capsule, and ligaments/cartilage) would play a significant role in posttraumatic stiffness, they found in fact that the  ligaments and cartilage caused 52% of the lost motion after 21 days of free motion and 74% of the contracture after 42 days of free motion. With this information, clinical therapies such as pharmacologic infiltrations or biophysical energy delivered to the ligaments or cartilage could be investigated. In addition, refined surgical techniques focused on these structures could be proposed and analyzed. This study represents a small preclinical step in further understanding the mechanisms of joint contracture, but it provides a foundation on which further investigations can be built.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

2018 EST Awards: And the Winners Are…

JBJS Essential Surgical Techniques (EST)  and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) article, and the other for the best Key Procedures (KP) video published during each calendar year.

We are pleased to announce the winners for 2018:

Full open access to both articles is available for a limited time.

Submissions for the 2019 EST Awards are currently being accepted.

Benchmark Data on Aseptic Revision after Knee Replacement

The main advantage of joint registries is their large number of recorded procedures, ideally with very few patient “types” not represented in the database. This is the case with the Australian Orthopaedic Association National Joint Replacement Registry, which includes data on almost 100% of all joint replacements performed in Australia since 2002. In the February 20, 2019 issue of The Journal, Jorgenson et al. analyze almost 6,000 major aseptic total knee arthroplasty (TKA) revisions from a cohort of 478,000 primary TKAs registered between 1999 and 2015. This analysis provides robust benchmark data for patients and surgeons, although it comes too late for the 3% of patients who required such a revision surgery within the 15-year study period.

The authors found that fixed bearings were revised for aseptic reasons at a significantly lower rate than mobile bearings (2.7% vs 4.1%, respectively) and that patients <55 years old had an almost 8-fold higher revision rate compared to patients ≥75 years old ( 7.8% versus 1.0%, respectively). The study also found lower aseptic revision rates with minimally stabilized total knee prostheses compared to posterior-stabilized prostheses, and higher aseptic revision rates with completely cementless fixation relative to either hybrid or fully cemented fixation. These are valuable data for arthroplasty surgeons in terms of selecting implants and surgical techniques and for preoperative counseling of patients—especially younger ones. While many of these findings have been previously reported, these registry-based results add significant strength to published data.

Ideally, data such as these would be controlled for confounding variables such as surgeon experience and additional patient-specific variables such as activity demands and medical comorbidities. Still, these data provide useful prosthesis-specific factors for shared decision making with patients. We look forward to more helpful information from this and other national joint registries and encourage the continued growth of similar registries in other subspecialties.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Smoking, Depression Adversely Affect Outcomes after TAA

After some relatively poor results in the 1980s, there was a “reboot” with total ankle arthroplasty (TAA) in the late 1990s to improve outcomes so that TAA would provide a reliable treatment for patients with end-stage ankle arthritis. Advances in the understanding of the biomechanical requirements for ankle prostheses and which patients might benefit from them the most—plus the realization  that TAA is a technically demanding surgical procedure that requires advanced education—have vastly improved the outcomes of these procedures. In fact, TAA has become reliable enough that we can now begin to tease out the patient variables that seem to affect outcomes.

In the February 6, 2019 issue of The Journal, Cunningham et al. use an extensive clinical TAA registry to identify patient characteristics that impact TAA outcomes. The good news is that, 30-plus years after the inauspicious outcomes of first-generation TAA, overall pain and function significantly improved among the patients in this study. However, current smoking was associated with poorer patient outcomes at the 5-year follow-up, as it seems to be with the vast majority of orthopaedic procedures. Also, at a mean 1- to 2-year follow-up,  a previous surgical procedure on the ankle was associated with significantly smaller improvements in at least 1 patient-reported outcome. This makes sense because prior surgery leads to scarring and its attendant risk of infection and increased difficulty with exposure and the ideal placement of TAA components. Cunningham et al. also identified depression as being associated with worse TAA outcomes at all follow-up points, adding to our already ample body of evidence that patient psychological factors play a major role in orthopaedic surgical results.

Interestingly, these authors found that patients undergoing staged bilateral ankle arthroplasty did not do as well as those undergoing simultaneous bilateral TAAs. And somewhat surprisingly, the authors found obesity to be associated with better outcomes at the 5-year follow-up. This may be related to increased bone density and greater soft-tissue coverage, but this finding is still seemingly counterintuitive based on everything else we know about the negative associations between obesity and outcomes of other joint replacements.

As more surgeons and orthopaedic centers make use of TAA, it will be important for us to follow the lead of the total knee and total hip communities in providing large datasets to further clarify which factors—patient-related and surgical—lead to the best and worst patient outcomes. This study by Cunningham et al. provides a starting point upon which other research will hopefully build.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Ankle Surgery: Who Should Do It?

The relationship between orthopaedic foot and ankle surgeons and podiatric surgeons has been checkered. Many have advocated that the orthopaedic community should isolate itself from interaction with the podiatric community. Conversely, a smaller group of orthopaedic foot and ankle surgeons have recommended sharing CME endeavors with podiatric surgeons, and combining clinical services with them. As long as individual states continue to legislate surgeon scope-of-practice matters (38 states currently allow podiatric surgeons to perform ankle surgery), it seems to me that shared learning, combined clinical services, and collaborative research make the most sense for advancing foot and ankle care for as many patients as possible. We should all be willing to work with our surgical colleagues to improve everyone’s decision making and skill.

In the January 16, 2019  issue of The Journal, Chan et al. probe an administrative database to evaluate several outcomes after total ankle arthroplasty (TAA) and ankle arthrodesis performed by both types of surgeon. Probably because many podiatrists self-limit their practices to forefoot surgery, podiatric surgeons provided the treatment for only 18% of the patients in both ankle-surgery groups. When podiatrists were the primary surgeon, the authors found increased lengths of stay for both procedures and increased hospital costs for arthrodesis patients. The authors did not investigate the reasons for these increases, but they should be investigated in the future. Chan et al. did find that, in general, podiatric surgeons operated on sicker patients and tended to work in smaller, non-teaching hospitals.

The authors also found an increasing percentage of these procedures being performed by podiatrists over the period from 2011 to 2016. This is likely related to multiple factors, including variable availability of orthopaedic foot and ankle surgeons relative to podiatric surgeons in many communities, and an increased number of podiatry training programs that specialize in hindfoot surgery.

It seems to me that data like these from Chan et al. should be shared with both communities to foster discussions regarding how to optimize length of stay, costs, and patient outcomes across the board. The goal should always be to raise every surgeon’s level of care for the benefit of all patients.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Unexplained Pain After TKA? Duloxetine Might Help

Somewhere between 10% and 15% of patients are unsatisfied with their outcome after primary total knee arthroplasty (TKA). In some cases, dissatisfaction is related to poor range of motion, but more often it is related to residual—or even intensified—pain in the knee several weeks after surgery.

In the January 2, 2019 issue of The Journal, Koh et al. report the results of a prospective randomized trial assessing the effects of duloxetine (Cymbalta) in TKA patients who were screened preoperatively for “central sensitization.” In central sensitization, a hyperexcitable central nervous system becomes hypersensitive to stimuli, noxious and otherwise.

Koh et al. randomized 80 centrally sensitized patients (mean age of 69 years), 40 of whom received a multimodal perioperative pain management protocol plus duloxetine, and 40 of whom received the multimodal protocol without duloxetine. During postoperative weeks 2 through 12, patients taking duloxetine reported better results in terms of pain and functional and emotional outcome measures than those not receiving the drug. Patients in the duloxetine group expressed greater satisfaction with pain control (77% vs 29%) and daily activity (83% vs 52%) at postoperative week 12, compared with those in the control group.

This research represents an important advance in identifying and treating patients who are prone to poor outcomes after TKA. The concept of central sensitization is relatively new to the orthopaedic community, and this pharmacologic intervention is likely to be just the first among many that will help these patients. I think it is probable that other, nonpharmacological interventions will eventually be as or even more successful in helping TKA patients with central sensitization. Koh et al. make a valuable  contribution in this article by educating us as to the neurophysiologic basis of this condition, and their work should pave the way for more important research in this area.

Marc Swiontkowski, MD
JBJS Editor-in-Chief