Subtalar Joint’s Middle Facet Yields Insight into Flatfoot
Many foot and ankle surgeons would relish a simple measurement made from a readily available imaging modality to help detect whether patients with adult acquired flatfoot deformity (AAFD) are at high risk for progressive collapse—and to help them with surgical planning. According to the findings from a case-control study by de Cesar Netto et al. in the October 16, 2019 issue of The Journal of Bone & Joint Surgery, that wish may soon be realized.
The authors made standing, weight-bearing computed tomography (CT) scans of 30 patients with stage-II AAFD (mean age of 57.4 years) and 30 matched controls (mean age of 51.8 years). From those images, 2 fellowship-trained surgeons, who were blinded regarding the patient cohorts, measured the amount of subluxation (percentage of uncoverage) and the incongruence angle of the middle facet of the subtalar joint in the coronal plane. The authors found substantial to almost perfect intraobserver and interobserver reliability for both measurements.
Based on these middle-facet measurements, the mean value for joint uncoverage in patients with AAFD was 45.3% compared with 4.8% in controls. Similarly, the mean incongruence angle in the AAFD group was 17.3° in the AAFD group and 0.3° in controls. Further analysis led the authors to conclude that “an incongruence angle of >8.4° and an uncoverage percentage of 17.9% were found to be highly diagnostic for symptomatic stage-II AAFD.”
De Cesar Netto et al. say the biomechanics of the subtalar joint made focusing on the middle facet a sensible approach, and they attributed the high reliability of the measurements to the relatively simple anatomy of the middle facet. Still, because clinical outcomes were not assessed in this study, the role of the middle facet as a marker of peritalar subluxation and a tool for deformity correction in AAFD patients needs further investigation in prospective, longitudinal studies.
Association ≠ Causation: Are Steroid Injections for OA Risky?
A recent report in Radiology citing possible complications from injecting steroids into painful joints with osteoarthritis (OA) has received lots of attention in the mainstream media. Radiologists from Boston, Germany, and France reviewed the existing literature and found an association between intra-articular steroid injections and a small increased risk of four adverse joint findings: accelerated OA progression, subchondral insufficiency fracture, complications from osteonecrosis, and bone loss. However, the study did not include a control group that did not receive injections, and therefore it cannot be used to assess whether injections are associated causally with the adverse joint findings.
In an interview with Boston radio station WBUR, lead author Ali Guermazi, MD stressed the point that readers should not conclude from this report that steroid injections cause these complications, adding that additional research in this area is “urgently needed.” In the same radio coverage, Jeffrey Katz, MD, a professor of orthopaedic surgery at Boston’s Brigham & Women’s Hospital and a Deputy Editor at JBJS, said patients who have received such injections or plan to should not be overly worried. However, he added that “for clinicians and patients who’ve been doing injections for several years, it’s worth it to pause and say, ‘Do we want to discuss [again] what we think are the benefits and risks of this.’”
FDA White Paper Cites JBJS “Case Connections” Article
There are 15 references to JBJS studies in the recently published 149-page white paper on “Biological Responses to Metal Implants,” from the FDA’s Center for Devices and Radiological Health. Most of those references are made in Section 7.5.1 (pp. 54-57), which focuses on orthopaedic devices.
The plethora of JBJS references is not surprising, but we were happy also to see that a JBJS “Case Connections” article was cited twice in the white paper. While most of the section on orthopaedic devices discussed metal-on-metal (MoM) hip problems, the FDA noted that adverse biological responses to metals in orthopaedics sometimes occur in the upper extremity. It did so by citing “Adverse Local Tissue Reactions in the Upper Extremity,” which appeared in the May 24, 2017 issue of JBJS Case Connector. The FDA white paper cautioned that metal wear debris-related adverse reactions have occurred with shoulder suture anchors (five cases of which are described in the “Case Connections” article) and with intramedullary humeral nailing (one case of which is described in the “Case Connections” article).
Among the take-home points made by co-authors Thomas Bauer and Allan Harper in the cited “Case Connections” article is this: “Patients with shoulder suture anchors who develop delayed-onset pain and/or stiffness, osteolysis, chondrolysis, or early arthropathy should be evaluated and consideration should be given to the removal of loose or prominent anchors to lessen the risk of articular damage.”
Surgeon Volume Matters for TKA Alignment
The retrospective multicenter study of 1,570 primary total knee arthroplasties (TKAs) by Kazarian et al. in the October 2, 2019 issue of JBJS focused on evaluating the impact of surgeon volume and training status on implant alignment. But the most surprising (and concerning) finding was that even among high-volume attendings—the best-performing of the three surgeon cohorts studied—the proportion of TKA alignment “outliers” was still high.
The authors radiographically measured 3 postoperative TKA alignment parameters: medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA). Using established thresholds for “outliers” and “far outliers” for those 3 measurements, the authors compared the radiographic findings among surgeries performed by high-volume attendings (≥50 TKAs/year), low-volume attendings (<50 TKAs/year), and trainees (supervised residents or fellows).
As has been shown in similar studies of total hip arthroplasty (THA), the group of high-volume attendings outperformed the low-volume attendings and the trainee group on nearly all measurements assessed in this study. Interestingly, in terms of TKA alignment, the low-volume attending group and the trainee group performed similarly.
Kazarian et al. express concern that “even the most accurate cohort in our study, [the high-volume attendings], placed only 69.0% of knees in optimal alignment for all 3 measurements.” While the authors admit that implant alignment is not a perfect proxy for clinical outcomes, they argue that “gross alignment outliers are likely to have an impact on knee function, kinematics, and wear characteristics.” Citing literature suggesting that the use of robotic-arm assistance may improve TKA alignment, the authors surmise that employing such technology to assist low-volume surgeons or trainees might optimize alignment and improve outcomes, despite the added up-front cost of the technology.
“It’s So Broken!”
Understanding the mechanism behind a bone fracture helps orthopaedic surgeons select the best approach to reduction and fixation. But patients who present emergently and in great pain are often not able to articulate exactly what happened. Furthermore, when the orthopaedic literature describes mechanisms of injury in words, such as “a high-energy abduction and external rotation of the ankle…,” it leaves a lot to the imagination.
The cell-phone video below had the unintended positive consequence of helping the orthopaedic surgeon understand how this ankle injury—a Weber Type C high fibula fracture, with a spiral pattern, a posterior butterfly, and a large posterior malleolus fracture involving 40% of the articular surface—came about.
The injury was treated using a posterolateral approach to the posterior malleolus. Lag screw fixation was followed by posterior plating of the Weber C level fibula fracture. The syndesmosis was found to be intact during intraoperative testing, and the patient is recovering well.
The Softer Side of Better Patient Outcomes
It goes almost without saying that a patient’s return to work after an orthopaedic injury or musculoskeletal disorder would correlate with the severity of the condition. But what about the connection between return to work and a more “touchy-feely” parameter, such as the patient-surgeon relationship?
Dubert et al. conducted a longitudinal observational study of 219 patient who were 18 to 65 years of age and had undergone operations for upper-limb injuries or musculoskeletal disorders. In the August 7, 2019 issue of JBJS, they report that a positive relationship between patient and surgeon hastened return to work and reduced total time off from work.
At the time of enrollment (a mean of 149 days after surgery), the authors assessed the patient-surgeon relationship with a validated, 11-item questionnaire called Q-PASREL, and they collected patients’ functional and quality-of-life scores at the same time. The authors then tracked which patients had returned to work 6 months later, and they calculated how many workdays those who did return had missed.
The Q-PASREL questionnaire explores surgeon support provided to the patient, the patience of the surgeon, the surgeon’s appraisal of when the patient can return to work, the cooperation of the surgeon regarding administrative issues, the empathy perceived by the patient, and the surgeon’s use of appropriate vocabulary.
Here is a summary of the findings:
- At 6 months after enrollment, 74% of patients who had returned to work had given their surgeon a high or medium-high Q-PASREL score. By contrast, 64% of the patients who had not returned to work had given their surgeon a low or medium-low Q-PASREL score.
- The odds of returning to work were 56% higher among patients who gave surgeons the highest Q-PASREL scores compared with those who gave surgeons the lowest scores.
- The “body structure” subscore on one of the functional measurements and the Q-PASREL quartile were the only two independent predictors of total time off from work among patients who had returned to work.
After asserting that their study “confirms that surgeons’ relationships with their patients can influence the patients’ satisfaction and outcomes,” Dubert et al. go on to suggest that the findings should prompt surgeons to “work on empathy, time spent with their patients, and communication.” While they rightly claim that such improvements would entail “little financial investment and no side effects,” perhaps the authors, who practice in France, underestimate the effort that goes into changing behavior—and into addressing the time constraints imposed by the US health care system?
AI and Medical Ethics: The Minds Must Meet
This post 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.
Artificial intelligence (AI) is no longer on the horizon; it is here and its number of “medical” applications, such as radiographic interpretation, is growing. Given the spectrum of potential uses of AI in medical decision making, consideration of medical ethics is essential, says Alan M. Reznik, MD, MBA in a recent AAOS Now article (see link below).
First, Dr. Reznik reviews the four basic elements of medical ethics:
- Autonomy—coercion-free independence of thought and decision making
- Justice—the assurance that the burdens and benefits of new or experimental treatments are distributed throughout all groups
- Beneficence—the intent of doing good for the patient
- Non-maleficence—the goal of doing no harm to the patient or society as a whole
Dr. Reznik goes on to observe that neural networks, the brains behind AI, have no inherent ethical reasoning. With the ability of neural networks to process massive amounts of human data, AI can and will “find and reinforce all preexisting biases in the dataset being used to ‘train’ it,” writes Dr. Reznik.
Here are 4 examples of why AI must conform to the four basic ideals of medical ethics:
Autonomy: The use of AI by insurance companies might yield fewer surgical approvals—saving carriers money, but denying individuals appropriate care. If that happens, “patient and physician autonomy will continue to be lost,” writes Dr. Reznik.
Justice: In AI-based epidemiology, the use of zip codes may introduce and/or amplify a wide range of socioeconomic, religious, and racial biases. AI applications that use addresses or zip codes “may need to be justified and checked for unethical bias each time they are used,” cautions Dr. Reznik.
Beneficence: Although “justice” might dictate decreased use of addresses, zip codes, and genetic information in AI-based medical applications, Dr. Reznik points out that to protect “beneficence” for individuals, some of that sensitive data will have to be included.
Nonmaleficence: The question here, Dr. Reznik writes, is “how AI will balance individual needs versus society and differing cultures in daily medical care.”
Reference
Click here to read Applying the Four Basic Principles of Medical Ethics to Artificial Intelligence
Marian Frauenthal Sloane, MD: Ahead of Her Time
In 2016, only 6.5% of practicing orthopaedic surgeons in the US were women. By contrast, 49% of all medical students in the US are women. That apparent discrepancy has sparked concern, conversations, and action in the orthopaedic community.
The current gender imbalance in orthopaedics would be even more stark were it not for two trailblazing women who lived during the early part of the 20th century. One of them, Ruth Jackson, MD, is the well-known namesake of today’s professional society of female orthopaedic surgeons. The other, New York City orthopaedist Marian Frauenthal Sloane, MD, has endured relative obscurity, until now.
The “What’s Important” essay by Hooper at al. in the June 5, 2019 issue of The Journal of Bone & Joint Surgery profiles Dr. Frauenthal Sloane’s short but influential career as orthopaedic surgeon, researcher, author (she coauthored 2 JBJS articles in the 1930s), and teacher. Despite the long way we still have to go to achieve gender diversity in orthopaedics, the authors of this fascinating sketch conclude by saying that “without [Dr. Frauenthal Sloane’s] brief but profound influence, women orthopaedists would probably be in a very different place today.”
Read related OrthoBuzz post about diversity in orthopaedic surgery.
Physician Practice Changes After Paying Malpractice Claims
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Matthew Deren, MD.
Malpractice. The word itself causes a visceral reaction for many of us in medicine. Although the vast majority of physicians will not pay a malpractice claim during their careers, there is still concern about the quality of care provided by doctors with multiple claims paid, either through out-of-court settlements or through court verdicts. The National Practitioner Data Bank (NPDB) was created, in part, to help prevent a doctor with a long list of malpractice claims paid from moving to a new geographic area for a “fresh start” without full disclosure of his or her claims history.
In the March 28, 2019 issue of The New England Journal of Medicine, Studdert et al. examined changes in practice characteristics among physicians who had paid malpractice claims from 2003 through 2015. By linking the NPDB to Medicare data, the authors identified a cohort of >480,000 physicians, 89.0% of whom had paid no malpractice claims. Nearly 9% of physicians had one paid claim, while the remaining 2.3% of physicians had two or more paid claims. That 2.3% accounted for 38.9% of all the claims paid during the study period.
A total of 19,098 (4%) of claims paid were in orthopaedic surgery, which made it the seventh most-sued specialty studied. When evaluating the subgroup of all physicians with ≥3 claims paid, the authors noted that they were more likely to be male, 50 years of age or older, and to practice in surgical specialties. In multivariate analysis, physicians with at least one paid claim were more likely to leave the practice of medicine than those with none. Finally, physicians with multiple paid claims were more likely to switch into small or solo practices, but the study found “no clear association between the number of claims and the propensity to relocate, within or between states.”
To be clear, the number of malpractice claims paid by a doctor is not necessarily a reliable indicator of quality of care, though many patients arrive at that conclusion. Just as important, this study doesn’t conclude that solo practitioners—in orthopaedics or any other specialty—are more likely to have paid a higher number of claims. There are many excellent physicians in solo practices across the United States.
Ultimately, this study shows that the majority of physicians have not paid a single malpractice claim and that physicians who have paid multiple claims are not more likely than other doctors to relocate their practice. These findings should help patients trust the various procedures that are in place to prevent the exceedingly small number of physicians with a long list of malpractice payouts from relocating in an attempt to leave their history behind them. From the physician viewpoint, the findings emphasize that the impact of malpractice claims goes beyond the emotional and personal into the realm of prompting changes in practice environment.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
Spine/Trauma 3D Navigation Software Recall
Brainlab AG is recalling its Spine & Trauma 3D Navigation software (version 1.0). The FDA has identified this as a Class I recall, the agency’s most serious category.
This navigation system provides images that help surgeons safely navigate instruments and implants used before and during minimally invasive surgeries. The software has been recalled because the displayed images may result in user misinterpretation and may prevent surgeons from accurately navigating surgical tools inside the patient.
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