OrthoBuzz has published several posts about osteoporosis, fragility fractures, and secondary fracture prevention. In the May 17, 2017 edition of JBJS, Bogoch et al. add to evidence suggesting that a coordinator-based fracture liaison service (FLS) improves engagement with secondary-prevention practices among inpatients and outpatients with a fragility fracture.
The Division of Orthopaedic Surgery at the University of Toronto initiated a coordinator-based FLS in 2002 to educate patients with a fragility fracture and refer them for BMD testing and management, including pharmacotherapy if appropriate. Bogoch et al. analyzed key clinical outcomes from 2002 to 2013 among a cohort of 2,191 patients who were not undergoing pharmacotherapy when they initially presented with a fragility fracture.
- Eighty-four percent of inpatients and 85% of outpatients completed BMD tests as recommended.
- Eighty-five percent of inpatients and 79% of outpatients who were referred to follow-up bone health management were assessed by a specialist or primary care physician.
- Among those who attended the referral appointment, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.
The authors conclude that “a coordinator-based fracture liaison service, with an engaged group of orthopaedic surgeons and consultants…achieved a relatively high rate of patient investigation and pharmacotherapy for patients with a fragility fracture.”
In the April 5, 2017 issue of The Journal, Noureldin et al. analyzed more than 14,000 procedures from the NSQIP database to determine the rate of unplanned 30-day readmission after outpatient surgical procedures of the hand and elbow. The 1.2% rate seems well within the range of acceptability, particularly because the more than 450 institutions contributing to this database probably serve populations who don’t have the best overall health and comorbidity profiles.
Missing causes for about one-third of the readmissions illustrate one issue with data accuracy in these large administrative datasets. While the authors acknowledged a “lack of granularity” as the greatest limitation in analyzing large databases, they added that the readmissions with no listed cause “were likely unrelated to the principal procedure.”
It was not surprising that infection was the most common cause for readmission. However, it would have been nice to know the rate of confirmed infection via positive cultures, as I suspect many of these patients were readmitted for erythema, swelling, warmth, and discomfort associated with postoperative hematoma rather than infection.
Regardless of the need for higher-quality data on complications following outpatient orthopaedic surgical procedures, this analysis gives us more confidence that the move toward outpatient surgical care in our specialty is warranted. I think most patients would rather sleep in their own home as long as preoperative comorbidities and ASA levels are considered and adequate postoperative pain control can be achieved in an outpatient setting. The trend toward outpatient orthopaedic treatment is likely to continue as we gather higher-quality data and better understand the risk-benefit profile.
Marc Swiontkowski, MD
Every month, JBJS publishes a Specialty Update—a review of some of the most pertinent and impactful studies published in one of 13 orthopaedic subspecialties during the previous year. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 15, 2017 Specialty Update on hand and wrist surgery, to select five of the most clinically compelling findings from among the more than 40 he cited in the article.
Carpal Tunnel Syndrome
—The AAOS published updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome (CTS). Among the conclusions are the following:
- Thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out.
- High body mass index and repetitive hand and wrist actions are associated with an increased risk of developing CTS.
- Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment.
- There is no benefit to routine postoperative immobilization after CTS surgery.
—If a distal radius fracture is displaced, especially in an elderly patient, should one proceed with nonoperative or operative treatment? A systematic review/meta-analysis1 involving more than 800 patients 60 years of age or older found that operatively treated patients had greater grip strength and better restoration of radiographic parameters than nonoperatively treated patients. However, those who underwent surgery also experienced more complications (primarily hardware-related) that required surgery.
Thumb and Digit Arthritis
—There are a myriad of treatments for the management of basilar thumb arthritis, ranging from trapeziectomy to fusion. Which one is better, especially if the scaphotrapeziotrapezoid joint is not involved? A prospective study was conducted randomizing women older than 40 with basal thumb joint arthritis to trapeziectomy and suspension arthroplasty or carpometacarpal joint arthrodesis. After a mean follow-up of 5.3 years, those in the trapeziectomy-suspension arthroplasty group had significantly better pain reduction and function.2 Researchers halted the study prematurely due to increased complications in the arthrodesis group.
Outcome Measurement Tools
—Among the many patient-reported outcome measures for the upper extremity, which should be used for which conditions? For distal radius fractures, a systematic approach has been proposed3 that captures outcomes across five domains: range of motion and grip strength, patient-reported scores of disability and function, complications, pain, and radiographs.4
—Is there any way to make the collection of patient-reported outcomes easier and less time-consuming? An assessment that compared two forms of computerized adaptive tests (CATs) with the DASH (Disabilities of the Arm, Shoulder and Hand) measure among 379 hand-clinic patients found that the CAT required fewer questions to complete than the DASH, yet maintained excellent reliability.5
- Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients. A systematic review and meta-analysis. J Hand Surg Am. 2016 ;41(3):404–13. Epub 2016 Jan 20.
- Spekreijse KR, Selles RW, Kedilioglu MA, Slijper HP, Feitz R, Hovius SE, Vermeulen GM. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a 5-year follow-up. J Hand Surg Am. 2016 ;41(9):910–6.
- Teunis T, Ring D. Comprehensive outcome assessment after distal radius fracture. J Hand Surg Am. 2016 ;41(8):e257. Epub 2016 Jun 11.
- Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Distal Radius Outcomes Consortium. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565–73.
- Beckmann JT, Hung M, Voss MW, Crum AB, Bounsanga J, Tyser AR. Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test. J Hand Surg Am. 2016 ;41(7):739–744.e4. Epub 2016 Jun 3.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Even before hand surgery became a specialty, the characteristics of the thumb that enabled pad-to-pad opposition (and therefore fine motor function) were well-recognized: shorter length, fewer bony segments, and pronated position relative to the fingers; a wide first web space; and intrinsic muscle control of abduction, rotation, and pinch. Although these principles were used to devise surgical procedures to restore thumb function prior to Buck-Gramcko’s landmark JBJS article in 1971, most were used for a small number of patients, with limited information available about outcomes. Thumb absence is uncommon, and no hand surgeon was able to gain sufficient experience with index pollicization to refine and enhance the technique until the confluence of Buck-Gramcko’s exceptional skill and one of the major medical catastrophes of the 20th century.
Dieter Buck-Gramcko was born in Hamburg, Germany in 1927. Following World War II, he trained in general and trauma surgery and became one of the first hand surgeons in Germany.1 Between 1957 and 1962, thalidomide was marketed in Germany as a sedative, but it also inhibited angiogenesis, causing limb malformations, including thumb deficiency, when fetuses were exposed to the drug during limb development.2 The resulting large number of German infants with thumb deficiency provided Buck-Gramcko with the opportunity to modify the technique of index pollicization and study the outcomes of his modifications to improve results. He described his findings and results in this landmark article.
His careful description of index pollicization includes the principles and techniques that remain the hallmarks of this operation. His diagram of reduction of bones and joints (Figure 3 of his classic article, shown below) is a simple and elegant depiction of the principles of this complex operation. His rigorous follow-up, measurement of outcomes, and propensity to criticize his own work to improve results are all apparent in this article, which provides an excellent example of applying the scientific method. Not surprisingly, Buck-Gramcko remained rigorous and objective throughout his long career; 20 years later, he published another article focused on complications and poor outcomes after index-finger pollicization.3
Index pollicization is one of the paramount operations of hand surgery, largely because Buck-Gramcko applied theoretical principles of thumb function, methodically and meticulously refined the technique of pollicization, studied the outcomes of his work, and passed this valuable information along in this classic article. It remains a useful guide to the performance of this operation almost half a century later. The thalidomide tragedy had a silver lining, thanks to Buck-Gramcko’s surgical skills, methodologic rigor, and scientific objectivity.
Michelle A. James, MD
JBJS Deputy Editor
- Hoffmann R, Lubahn JD. First Hand: Dieter Buck-Gramcko. Journal of Hand Surgery. 2013;38(5):988-90.
- Stephens T, Brynner R. Dark remedy: the impact of thalidomide and its revival as a vital medicine. Basic Books, N.Y.; 2009.
- Buck-Gramcko D. Complications and bad results in pollicization of the index finger (in congenital cases). Annales de Chirurgie de la Main et du Membre Supérieur 1991;10 (6):506-512).
In 2015, JBJS launched an“article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of March 2017, JBJS and OrthoBuzz readers will have access to the JOSPT article titled “The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial.”
In that clinical trial of 100 women with carpal tunnel syndrome randomized to receive either manual therapy or endoscopic decompression/release, researchers found that both interventions had similar outcomes in self-reported function and pinch-tip grip force at 3, 6, and 12 months of follow-up. However, at 1 month, there were significant between-group differences in favor of manual therapy. No changes in cervical range of motion were observed after either manual therapy or surgery at any time point.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.
Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.
It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.
The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”
However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.
For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.
But perhaps the most compelling question is — why do we need an AUC app in the first place? Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories? And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.
However, there is another, critically important theme to the AUC story. Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide. As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.” If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.
With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome. More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.
Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.
Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD.
In the December 21, 2016 edition of the Journal of Bone & Joint Surgery, Bunta, et al. published an analysis of data from the Own the Bone quality improvement program collected between January 1, 2010 and March 31, 2015. Over this period of time, 125 sites prospectively collected detailed osteoporosis and bone health-related data points on men and women over the age of 50 who presented with a fragility fracture.
The Own the Bone initiative is more than a data registry; it’s a quality improvement program intended to provide a paradigm for increasing the diagnostic and therapeutic recognition (i.e. “response rate”) of the osteoporosis underlying fragility fractures among orthopaedic practices that treat these injuries. With more than 23,000 individual patients enrolled, and almost 10,000 follow-up records, this is the most robust dataset in existence on the topic.
This initiative has more than doubled the response rate among orthopaedic practices treating fragility fractures. The number of institutions implementing Own the Bone grew from 14 sites in 2005-6 to 177 in 2015. According to Bunta et al., 53% of patients enrolled in the Own the Bone quality Improvement program received bone mineral density testing and/or osteoporosis therapy following their fracture.
Own the Bone was a natural progression of rudimentary efforts that came about during the Bone and Joint Decade, and it marks a strategic effort on the part of the American Orthopedic Association to identify and treat the osteoporosis underlying fragility fractures. Multiple studies have demonstrated that only 1 out of every 4 to 5 patients who present with a fragility fracture will receive a clinical diagnosis of osteoporosis and/or active treatment to prevent secondary fractures related to osteoporosis. Ample Level-1 evidence demonstrates that the initiation of first-line agents like bisphosphonates, or second-line agents when indicated, can reduce the chance of a subsequent fragility fracture by at least 50%. We know these medicines work.
We also know that osteoporosis is a progressive phenomenon. Therefore, failing to respond to the osteoporosis underlying fragility fractures means we as a medical system fail to treat the root cause in these patients. The fracture is a symptom of an underlying disease that needs to be addressed or it will continue to produce recurrent fractures and progressive decline in overall health.
The members of the Own the Bone initiative must be commended for their admirable work. We as an orthopedic community need to attempt to incorporate lessons learned through the Own the Bone experience into our practice to ensure that we provide complete care to those with a fragility fracture. The report from Bunta et al. represents a large—but single—step forward on the journey toward universal recognition and treatment of the diminished bone quality underlying fragility fractures. I look forward to additional reports from this group detailing their continued success in raising the bar of understanding and intervention.
Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN.
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 7-year-old girl who sustained a wrist injury from a fall off of monkey bars. An initial lateral radiograph is shown here. Clinicians attempted a closed reduction and applied a long arm cast. At the 1-week follow-up visit, radiographs showed additional displacement and increased dorsal angulation.
Select from among five possible choices for the greatest predictor of fracture displacement in the setting of distal radial metaphyseal fractures: increased fracture obliquity, a cast index ratio of less than or equal to 0.7, short arm casting, an intact ulna, or increased initial displacement of the radius.
Ulnar shortening osteotomy is a widely accepted procedure for surgical treatment of ulnar impaction syndrome, but many techniques require special instrumentation to achieve accurate shortening, adequate fixation, and sufficient rotational control. In the November 2, 2016 issue of The Journal of Bone & Joint Surgery, Papatheodorou et al. report on outcomes in 164 patients who underwent so-called “step-cut” osteotomies for positive ulnar variances that ranged from +1 to +6 mm.
The technique itself, which utilizes a standard neutralization plate and lag screw for fixation, is summarized and illustrated in the article. The authors emphasize that the step-cut approach does not require special jigs or instrumentation.
Patients were followed for a median of 66 months. The overall union rate was 98.8%; postoperative ulnar variance ranged from –1 to +1.5 mm after a mean overall ulnar shortening of 2.5 mm. All patients had significant postoperative improvements in pain, range of motion, grip strength, and Mayo Modified Wrist Score. Plate removal due to irritation was necessary in only 12 (7.3%) of the patients.
The authors also found in these patients “a lower rate of degenerative changes at the distal radioulnar joint compared with rates reported in previous studies.” They attribute this to the relatively small amount of ulnar shortening with the step-cut procedure, which they surmise “diminishes the rate of articular incongruity and hence arthritis of the distal radioulnar joint.” On the cost side of the matter, the authors noted that at their institution, special ulnar osteotomy systems cost almost 10 times more than a standard neutralization plate.
Thumbs account for approximately 40% of human hand function, playing a critical role during work, play, and activities of daily living. Arthritis at the base of the thumb (basilar or trapeziometacarpal joint) is one of the most common forms of hand osteoarthritis, affecting as many as 40 percent of the female population older than 55.
This complimentary webinar, hosted jointly by The Journal of Bone & Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), will look at the efficacy of both nonoperative and surgical approaches to basilar thumb arthritis.
- Co-authors Jorge Villafañe, PT, PhD, and Joshua Cleland, PT, PhD, will discuss results from a randomized trial in JOSPTthat compared a multimodal program of exercise and mobilization to a placebo in the management of basilar thumb arthritis.
- E.R. Hovius, MD, co-author of a randomized trial in JBJS comparing trapeziometacarpal fusion with trapeziectomy plus ligament reconstruction, will delineate the findings from this Level I study.
Moderated by Sanjeev Kakar, MD, a hand surgeon at the Mayo Clinic in Rochester, Minnesota, the webinar will include additional perspectives from two expert commentators—Krysia Dziedzic, PhD, and Peter Stern, MD.