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
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.
Having passed the half-century mark with continued relevance, this classic JBJS article by T.G. Barlow, published in the British volume in 1962, rewards the reader with pearls and insights that can still help us make good decisions about treatment of infants with hip dysplasia. Exploring new approaches always pays rich dividends, and this report details Barlow’s observations from a five-year study (1957-1962) in which he examined all newborns at his hospital and followed them up at one year of age. This effort was undertaken at a time before the emerging field of pediatric orthopaedics had many full-time adherents.
Barlow studied nearly 10,000 newborns at the Hope Hospital in Manchester, England. He conducted the first examinations during the first week of life, in an era when newborns in the UK stayed in the hospital for at least one week. He carefully recorded his findings and made observations on incidence of hip dislocation, natural history, and treatment.
His first contribution, for which he is still remembered, was to show that in newborns, with their low resting muscle and tissue tension, the Ortolani test is often subtle, and a dislocated hip may escape notice. The Ortolani test was often impressive in older babies, but less so in newborns. Therefore, Barlow devised his eponymous test, which increases the proprioceptive feedback by applying axial pressure and provoking subluxation or dislocation. Simply put, it is often easier to feel the hip displacing with pressure than to feel it slip back in. The number of babies who have benefited from this method of early detection is too numerous to count!
Barlow’s other observations are equally relevant and useful. He observed that many babies with dislocatable but non-dislocated hips will stabilize naturally. He showed that only one-eighth of unstable hips will have a persistent dislocation, which is why we now only treat dislocated hips immediately upon detection. Recent articles1 have added further insights in this regard.
Barlow also showed that with a program of screening and treatment, no patient in his experience presented at a year of age with a hip dislocation. We still debate the proper method of early detection, but he properly targeted the neonatal period as the time that instability usually begins. Barlow also demonstrated a simple abduction splint made of aluminum and leather that holds the hips in flexion and abduction. Although the Pavlik harness has become more popular as an initial treatment, experts have recently come to realize that a fixed-angle brace can benefit some children who do not stabilize in a Pavlik.2
This classic article was fun to re-read and remains useful to general and pediatric orthopaedic surgeons. Barlow’s disciplined undertaking has shaped our understanding of this important disorder. The man and his insights are remembered for good reason.
Paul D. Sponseller, MD
JBJS Deputy Editor
- Upasani VV, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016 Jul 20;98(14):1215-21
- Sankar WN, Nduaguba A, Flynn JM. Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip. J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7.
Most insults to the sciatic nerve arise from intervertebral disc conditions or spinal stenosis. However, beyond these common etiologies for sciatic-nerve problems are a host of other, rarer causes. This month’s “Case Connections” explores 4 such peculiar examples.
The springboard case report, from the October 12, 2016 edition of JBJS Case Connector, describes 3 instances of sciatica caused by nerve compression from a perineural cyst arising from a paralabral cyst. All 3 patients were successfully treated with arthroscopic decompression. Three additional JBJS Case Connector case reports summarized in the article focus on:
- A 70-year-old woman with a history of thromboembolism who experienced sciatic nerve palsy from an anticoagulant-induced hematoma
- A 31-year-old woman with sciatic endometriosis who was successfully treated by a team of gynecologists, orthopaedists, and microsurgeons
- A 66-year-old woman in whom sciatic nerve injury occurred after repeated attempts at closed reduction of a dislocated hip prosthesis
Orthopaedists evaluating patients with symptoms characteristic of sciatic-nerve pathology should recognize that these symptoms may arise from a variety of etiological pathways. These patients require a complete history-taking, a thorough physical exam, and an attempt to rule out all possible lumbar causes.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, James Ninomiya, MD, MS, lead author of the September 21, 2016 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the nearly 70 studies summarized in the Specialty Update.
–A meta-analysis found no differences in short- and medium-term implant survivorship among the following three bearing combinations used in THA patients younger than 65 years of age: ceramic on ceramic, ceramic on highly cross-linked polyethylene, and metal on highly cross-linked polyethylene.1
Insight into Aseptic Loosening
–Pathogen-associated molecular patterns (“endotoxins”) on particulate wear debris may be partially responsible for aseptic loosening. An in vitro/in vivo study found that macrophages that did not express the pathogen-associated molecular pattern receptor called TIRAP/Mal had significantly diminished secretion of inflammatory proteins. Patients with a genetic polymorphism suppressing that receptor exhibited decreased osteolysis during in vivo experiments. This suggests that some patients may be genetically more prone to aseptic loosening.
THA in Patients with RA
–A systematic review/meta-analysis of patients who were and were not taking a TNF-α inhibitor for rheumatoid arthritis prior to hip replacement found that those taking the drug had an increased risk of perioperative infection, with an odds ratio of 2.47.2 These results suggest that in order to decrease the risk of perioperative infections, it may be prudent to discontinue these drugs in advance of proposed joint replacement surgery.
Delaying THA for Femoral Head Osteonecrosis
–A systematic review/meta-analysis of patients with femoral head osteonecrosis concluded that injection of autologous bone marrow aspirate containing mesenchymal stem cells during core decompression was superior by a factor of 5 to core decompression alone in preventing collapse of the femoral head and delaying conversion to THA.3 This information may lead to new treatment paradigms for osteonecrosis.
Preventing Post-THA Dislocations
–A systematic review/meta-analysis that included more than 1,000 patients who underwent THA with a posterior or anterolateral approach found similar dislocation rates among those who were and were not given post-procedure restrictions in motion or activity.4 This suggests that the use of traditional hip precautions may not be necessary, and in fact may impede the rate of recovery following joint replacement surgery.
- Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, TrousdaleRT. There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.
- Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP. Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis. Rheumatology (Oxford). 2016 Mar;55(3):573-82. Epub 2015 Oct 7.
- Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV. The role of “cell therapy” in osteonecrosis of the femoral head. A systematic review of the literature and meta-analysis of 7 studies. Acta Orthop. 2016 Feb;87(1):72-8. Epub 2015 Jul 29.
- Van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and precautions prevent dislocation after total hip arthroplasty? A systematic review and meta-analysis of the literature. Clin Rehabil. 2016 Apr;30(4):329-39. Epub 2015 Mar 31.
The incidence of primary total knee and hip arthroplasty is increasing steadily. While the success rates of these procedures are remarkable, failures do occur, and periprosthetic joint infection is the leading culprit in such failures. The standard treatment when deep infection strikes is a two-stage revision.
On Monday, November 14, 2016 at 8:00 PM EST, The Journal of Bone & Joint Surgery (JBJS) will host a complimentary webinar that examines prognostic factors affecting the success of two-stage revision arthroplasty for infected knees and hips.
- Tad M. Mabry, MD, coauthor of a matched cohort study in JBJS, will examine the impact of morbid obesity on the failure of two-stage revision TKA.
- JBJS author Antonia F. Chen, MD, will discuss results from a retrospective study that revealed an association between positive cultures at the time of knee/hip component reimplantation and the risk of subsequent treatment failure.
Moderated by JBJS Deputy Editor Charles R. Clark, MD, the webinar will include additional perspectives from two expert commentators—Daniel J. Berry, MD and Andrew A. Freiberg, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.
Seats are limited, so register now!