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Against All Odds, Syrian Doctor Lands US Orthopaedic Residency

Diebo WIThe February 7, 2018 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Dr. Bassel Diebo.

At a time when the suffering in Syria seems unremitting, Dr. Diebo tells of starting his surgery residency in a besieged Damascus hospital at the start of the Syrian uprising in March 2011. He came to America at the end of 2012; worked hard at NYU Hospital for Joint Diseases, the Hospital for Special Surgery, and  SUNY Downstate Medical Center; passed the USMLE exams; and landed an orthopaedic residency almost 6 years to the day after the Syrian uprising began.

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

Generalized Joint Laxity—A Risk Factor for Poor Outcomes After ACL Reconstruction

Joint Laxity InfoGraphic for OBuzzSometimes, being too flexible is not a good thing. In the February 21, 2018 edition of The Journal of Bone & Joint Surgery, Kim et al. show that patients with generalized joint laxity—those who can hyperextend their knees and elbows beyond 10°, for example—tend to have poorer knee-stability and functional outcomes after anterior cruciate ligament (ACL) reconstruction than those who have normal joint flexibility.

The authors studied 8-year outcomes among 163 patients who underwent a unilateral ACL reconstruction. In all cases, the same surgeon performed the same procedure (bone-patellar tendon-bone autograft), and all patients went through the same rehab program.

In terms of graft-rupture rates and contralateral ACL rupture rates over the study period, the authors found no statistically significant differences between the 122 patients without laxity and the 41 patients who were determined preoperatively to have generalized joint laxity. However, at the 8-year follow-up, the patients with laxity had less knee stability (as measured with Lachman and pivot-shift tests and an arthrometer) and worse knee function (as measured with the Lysholm and IKDC scales) than patients without laxity.

Taken together, these findings lead Kim et al. to conclude that “generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction.” We also noted that JBJS Deputy Editor Robert Marx, MD (@drrmarx) remarked on Twitter that “adding lateral ITB [iliotibial band] tenodesis may be helpful for more severe cases with significant knee hyperextension.”

Click here for a two-minute video summary of this study.

Choosing Wisely Now Addresses Pediatric Orthopaedics

choosing-wisely_logo_200x133OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew R. Schmitz, MD, a member of the JBJS Social Media Advisory Board.

The American Academy of Pediatrics (AAP) Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) recently issued a list of tests and treatments that physicians and patients should avoid. The list appears on the Choosing Wisely® website, an initiative of the American Board of Internal Medicine (ABIM) Foundation.

The list highlights 5 commonly encountered pediatric orthopaedic scenarios/conditions that often consume excessive time and resources with little or no clinical value in return. The Evidence Based Committee and Advocacy Committee of POSNA developed the peer-reviewed list and vetted it through both the POSNA Board of Directors and the AAP Executive Committee.

Although geared toward family and primary care physicians, the list contains important take-home points for orthopaedic surgeons who might have pediatric patients walk through their doors. The recommendations include the following:

  1. Screening ultrasound for developmental hip dysplasia is not needed if the newborn has no risk factors and has a clinically stable hip exam. The substantial rate of false positives with screening ultrasounds likely causes many children to undergo unnecessary treatment.
  2. Simple in-toeing does not require a radiographic workup or brace or surgical treatment in children younger than 8 years old. Unless there is severe tripping, falling, or marked asymmetry, a watchful waiting approach is best for this condition, which typically resolves with growth.
  3. Custom orthotics or shoe inserts are not needed for children with asymptomatic or minimally symptomatic flat feet. If the flatfoot is minimally symptomatic and flexible (arch reconstitutes when the child stands on his/her toes), it can be managed with observation or over-the-counter orthotics.
  4. Advanced imaging such as MRI or CT should not be ordered for most musculoskeletal conditions in children until all appropriate clinical, laboratory, and plain film examinations have been done. Most pediatric conditions can be accurately diagnosed with a good history, physical exam, plain radiographs, and occasional labs. Use advanced imaging only if a specific question arises from the preceding workup. CT scans expose patients to high levels of radiation and should be used judiciously. If MRI is deemed necessary, it is best to have the consulting orthopaedist order the MRI with specific protocols and sequences.
  5. Buckle fractures do not need follow-up radiographs if pain and tenderness have resolved after immobilization. These common pediatric injuries are inherently stable.

Both POSNA and the AAP should be commended on their evidenced-based and common-sense approach for tackling these common pediatric orthopaedic conditions.

Matthew R. Schmitz, MD is vice chair of the Department of Orthopaedics and chief of Pediatric Orthopaedics and Adolescent Sports Medicine at San Antonio Military Medical Center in Ft. Sam Houston, Texas.

Bundled Payments: Patient-Specific Care Calls for Patient-Specific Reimbursements

Hip Fracture for OBuzzThe bundled-payment model has found some early success within the field of orthopaedic surgery, most notably in joint replacement (see related OrthoBuzz post), However, more robust risk-adjustment methods are needed, especially in terms of patient factors. That is the message delivered by Cairns et al. in their retrospective analysis of Medicare data from 2008 to 2012 published in the February 21, 2018 edition of JBJS. The authors make a compelling case for improved risk stratification of hip- and femur-fracture patients to ensure that all patient populations have and retain access to appropriate care.

The authors analyzed reimbursements for the surgical hospitalization and 90 days of post-discharge care among nearly 28,000 patients who met inclusion criteria for the Surgical Hip and Femur Fracture Treatment (SHFFT) model proposed by the Centers for Medicare and Medicaid Services (CMS). Their findings highlighted various inconsistencies that could have unintended consequences if not accounted for in the bundled-payment model. For example, reimbursements were $1000 to $2000 lower for patients in their 80s, who tend to have more comorbidities that require more care, than for younger patients.  CMS proposed using Diagnosis Related Groups (DRGs) and geographic location to adjust for risk in its SHFFT bundled-payment model, but Cairns et al. identify several other factors (such as patient age and gender, ASA and Charlson Comorbidity Index scores, and procedure type) that could provide a more realistic stratification of risk.

The article clearly articulates how risk adjustments that don’t include more specific patient factors could lead to a multitude of unintended consequences for patients, providers, and the entire healthcare system. These findings could remain relevant now that CMS has announced an “advanced” voluntary bundled-payment model after the Trump administration cancelled SHFFT in late 2017.

Whatever bundled-payment model takes hold, the totality of the orthopaedic literature strongly suggests that the best outcomes are derived from making specific treatment plans for each patient based on the individual characteristics of his or her case. It seems reasonable that the best bundled-payment plans would do the same.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Excess Opioid Medication Video Summary

Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. 

Fixation Costs for Distal Radial Fracture

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value. 

Excess Prescription Opioids

Postoperative management in orthopaedic surgery accounts for a substantial portion of medications prescribed in the United States. 

Fragility Fracture Risk Prediction: Beyond BMD

BMD for OBuzzThis basic science tip comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Bone mineral density (BMD)—a measure of both cortical and trabecular bone—has been widely used as an index of bone fragility. The femoral neck and lumbar vertebrae are the areas most commonly measured with BMD, but hip osteoarthritis and lumbar spondylosis can mask systemic osteoporosis. In addition, the most common fragility fractures occur at the distal radius.

Investigators conducted a prospective study using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia to determine whether baseline skeletal parameters could predict fragility fractures in women. A second goal was to establish whether women who have fragility fractures experience bone loss at a faster rate than those who do not have fractures.

Among 149 women older than 60 years who had baseline and 5-year follow-up HR-pQCT, 22 had a fragility fracture during the study period and 127 did not. HR-pQCT is able to record total bone mineral density (Tt.BMD), trabecular bone mineral density (Tb.BMD), trabecular number (Tb.N), and trabecular separation (Tb.Sp).

The analysis showed that women with fragility fractures had lower baseline Tt.BMD (19%), Tb.BMD (25%), and Tb.N (14%), along with higher Tb.Sp (19%) than women who did not experience a fracture. Analysis of the tibia measures yielded similar results, showing that women with incident fracture had lower Tt.BMD (15%), Tb.BMD (12%), cortical thickness (14%), and cortical area (12%). Also, women with fractures had lower failure load (10%) with higher total area and trabecular area than women without fractures.

For each standard deviation decrease of a measure at the distal radius, the odds ratio for fragility fracture was 2.1 for Tt.BMD. 2.0 for Tb.BMD, and 1.7 for Tb.N. ORs for those measures at the tibia were similar.

In contrast to these findings, the annualized percent rate of bone loss was not different between groups with and without fractures. These results suggest that future fragility-fracture risk prediction should rely at least as much on bone architecture and strength as on simple BMD measurements.

Burt LA, Manske SL, Hanley DA, Boyd SK. Lower Bone Density, Impaired Microarchitecture, and Strength Predict Future Fragility Fracture in Postmenopausal Women: 5-Year Follow-up of the Calgary CaMos Cohort. J Bone Miner Res. 2018 Jan 24. doi: 10.1002/jbmr.3347 PMID: 29363165

PAO Results Hold Up over Intermediate Term

Periacetabular Osteotomy for OBuzzThe Bernese periacetabular osteotomy (PAO) has become the procedure of choice for treating symptomatic acetabular dysplasia. But how long-lasting are its benefits? Quite, according to one of the largest intermediate-term follow-up studies on this procedure, authored by Wells et al. in the February 7, 2018 edition of The Journal of Bone & Joint Surgery.

Among 154 hips (average patient age of 26 years) treated with PAO at a single center between 1994 and 2008, the survival rate, with total hip arthroplasty (THA) as the endpoint, was 92% at 15 years postoperatively. When failure was defined as a conversion from PAO to THA or a symptomatic hip, the hip-preservation rate was 79% at a mean follow-up of 10.3 years.

After carefully analyzing the data to identify factors that contributed to failure or success, the authors discovered that:

  • Hips with fair or poor joint congruency before surgery had 9 times the odds of failing when compared with hips that had good or excellent preoperative joint congruency.
  • Hips with a postoperative lateral center-edge angle of >38° had 8 times the odds of failure.
  • Hips that underwent a concurrent head-neck osteochondraplasty at the time of PAO had a 73% decrease in the odds of failing.

These data suggest that preventing excessive femoral head coverage and secondary impingement resulting from surgery improves hip survival. Consequently, Wells et al. reported that their institution, Washington University School of Medicine, “currently assess[es] for secondary impingement intraoperatively following PAO,…and, if it is present, osteochondroplasty of the head-neck junction is performed to relieve potential secondary femoroacetabular impingement.”

The authors also recommend against managing patients with symptomatic acetabular dysplasia with hip arthroscopy because “it fails to address the underlying pathomechanics found in developmental dysplasia of the hip.”

With New Technologies, Slow Adoption is Best

MoM for OBuzzThe enemy of the good is the better. It’s an axiom we hear during our surgical training, and it was my first thought when reading the article by Hunt et al. in the February 7, 2018 edition of JBJS.  The authors examine failure rates associated with the rapid adoption and widespread use of metal-on-metal (MoM) total hip arthroplasties (THAs) and hip resurfacings.

Carefully analyzing data from the National Joint Registry for England, Wales and Northern Ireland from 2003 to 2014, Hunt et al. ascertained that MoM hip resurfacings and MoM total hip arthroplasties resulted in 10-year revision rates that were almost 3 and 5 times higher, respectively, than the expected revision rates for standard hip procedures. This meant that within 10 years, there were almost 8 excess revisions for every 100 MoM hip resurfacings and almost 16 excess revisions for every 100 MoM total hip arthroplasties. Just as troubling was the finding that 20% of those excess revisions needed at least one additional revision within 7 years.

As orthopaedic surgeons, we strive to make things better for patients, which may tempt us to try a “new and improved” technology for a nominal (or presumed) improvement in outcome, when the one we are currently using works just fine. It is our responsibility as surgeons not to be blind to the unintended consequences new technologies may have on our patients.

I agree with the blunt directive Hunt et al. issue in the final sentence of their abstract: “This practice of adopting new technologies without adequate supporting data must not be repeated.”

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media