Here’s one thing about which medical studies have been nearly unanimous: Smoking is a health hazard by any measure. In the February 15, 2017 edition of The Journal of Bone & Joint Surgery, Tischler et al. put some hard numbers on the risk of smoking for those undergoing total joint arthroplasty (TJA).
After controlling for confounding factors, the authors of the Level III prognostic study found that:
- Current smokers have a significantly increased risk of reoperation for infection within 90 days of TJA compared with nonsmokers.
- The amount one has smoked, regardless of current smoking status, significantly contributed to increased risk of unplanned nonoperative readmission.
In a commentary on the Tischler et al. study, William, G. Hamilton, MD says, “…as physicians, we should work cooperatively with our patients to enhance outcomes by attempting to reduce these modifiable risk factors. We can educate patients and can suggest smoking cessation programs and weight loss regimens that may not only improve the risk profile during the surgical episode, but also improve the patients’ overall health.”
Hip dislocation is one of the most common perioperative complications of total hip arthroplasty (THA). The latest “Case Connections” article examines an often-overlooked spinal basis for THA dislocations, 2 cases of dual-mobility hip-bearing dissociations during attempted closed reduction for post-THA dislocations, and a unique application of Ilizarov distraction to treat a chronic post-THA dislocation.
The springboard case report, from the February 22, 2017, edition of JBJS Case Connector, describes the case of a 63-year-old woman who had experienced 4 anterior dislocations in less than 3 years after having her left hip replaced. Each dislocation was accompanied by lower back pain, and the patient also reported substantial pain in the contralateral hip. The authors emphasize the importance of recognizing pelvic retroversion and sagittal spinal imbalance before performing total hip arthroplasty.
Two additional JBJS Case Connector case reports summarized in the article focus on:
- The risks of performing closed reduction on patients with a dislocated dual-mobility hip design.
- A unique application of Ilizarov distraction to lengthen soft tissues for femoral-component reduction in a patient with a chronically dislocated hip replacement.
While closed reduction with the patient under sedation is a frequently employed first-line tactic that is often successful for dislocated THAs, these 3 cases show that creative surgical interventions may be necessary for optimal outcomes in patients with “complicated” hips and/or recurrent dislocations.
It is well accepted that kids with Legg-Calve-Perthes (LCP) disease do best when their condition is diagnosed and managed before 6 years of age. Surgical treatment is often recommended for children 6 years and older who have more severe femoral-head involvement, and orthopaedists perform combined pelvic and femoral varus osteotomies on some of those children.
In the February 1, 2107 edition of The Journal, Mosow et al. compare 10-year outcomes in 52 LCP patients who underwent combined osteotomies (mean age at surgery of 7.9 years) with results reported in the literature for single pelvic or femoral osteotomies. Although the postoperative radiographic and functional results after combined osteotomy were good, they were overall no better than those reported in the literature for either osteotomy alone.
The authors admit that in the absence of a randomized study design, these findings should be interpreted with caution, but they conclude that “it is not recommended that combined osteotomies for this age group routinely be used.”
Single-anesthetic bilateral total hip arthroplasty (THA) has had a historically high perioperative complication profile. However, a matched cohort study by Houdek et al. in the January 4, 2017 edition of JBJS comparing single-anesthetic versus staged bilateral THA over four years found no significant differences between the two procedures in terms of:
- Risks of revision, reoperation, or complications (including DVT/PE, dislocation, periprosthetic fracture, and infection; see graph, where blue line represents single-anesthetic and red line indicates staged)
- Perioperative mortality
- Discharge to home versus rehab
The single-anesthetic group (94 patients, 188 hips) experienced shorter total operating room time and hospital length of stay than the matched cohort, and consequently the single-anesthetic approach lowered the relative total cost of care by 27%.
While the Mayo Clinic authors concede the potential for selection bias in this study (e.g., there was no standardized protocol for determining eligibility for inclusion in either group), they say that they currently consider single-anesthetic bilateral THA for patients with bilateral coxarthrosis who are <70 years of age, relatively healthy, and/or have bilateral hip contractures that would make rehabilitation difficult.
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
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.
The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.
The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:
- Shoulder OCD in a teenage baseball player that was treated arthroscopically
- Early elbow OCD in young throwers
- Three cases of bilateral femoral head OCD that occurred in multiple members of the same family
Among the take-home points emphasized in this Case Connections article:
- MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
- Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
- There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.
“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
In the November 16, 2016 edition of The Journal of Bone & Joint Surgery, Kim et al. improve our understanding of how blood flow is restored to the necrotic femoral head in Legg-Calve-Perthes disease. Using a series of perfusion MRI scans, the authors evaluated 30 hips with Stage-1 or -2 disease; 15 of the hips were treated conservatively, and 15 underwent one of three operative interventions.
Revascularization rates varied widely (averaging 4.9% ± 2.3% per month), but the revascularization pattern was similar, converging in a horseshoe-shaped pattern toward the anterocentral region of the femoral epiphysis from the posterior, lateral, and medial aspects of the epiphysis. The MRIs yielded no evidence of regression or fluctuation of perfusion of femoral heads, which casts some doubt on the proposed repeated-infarction theory of pathogenesis for this disease.
In a related commentary, Pablo Castaneda emphasizes that the study was not designed to evaluate the effects of different treatments, but he says knowing about an MRI pattern that is predictive of final outcomes in Legg-Calve-Perthes disease “has potential for improving our prognostic abilities.” Still, neither the commentator nor the authors suggest routinely obtaining serial MRIs in this patient population.
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