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.
Sometimes, patients with painful knee osteoarthritis do not get sufficient pain relief with conservative treatments and do not want (or are not suitable candidates for) arthroplasty. Now, with the advent of genicular nerve radiofrequency ablation (GNRFA), such patients have another option.
As described in a recent issue of JBJS Essential Surgical Techniques, GNRFA has been shown to provide consistent pain relief for 3 to 6 months. Using heat generated from electricity delivered via fluoroscopically guided needle electrodes, the procedure denatures the proteins in the 3 genicular nerves responsible for transmitting knee pain. Although there is a paucity of high-quality studies on the efficacy of this procedure, one study found that, on average, GNRFA led to improvement of >60% from baseline knee pain for at least 6 months.
In the authors’ practice, GNFRA is generally not repeated if it is ineffective the first time, but the procedure has been shown to be safe when administered repeatedly in patients who respond well. Proper positioning of the electrodes is essential, but the authors caution that without ample experience, “it may be difficult to isolate the exact anatomic location of ≥1 of the genicular nerves.”
General anesthesia is not required for the procedure, which is commonly performed by interventional pain specialists. Despite theoretical concerns, no Charcot-type joints have been reported after GNRFA. The authors emphasize, however, that the procedure provides temporary relief at best; it does not eliminate the potential for nerve regrowth and does not alter the arthritic disease process. Even more importantly, GNRFA needs to be studied with higher-level clinical research designs, ideally an adequately powered sham/placebo-controlled randomized trial.
For more information about JBJS Essential Surgical Techniques, watch this video featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski.
The indications for treating total hip arthroplasty (THA) dislocations by cementing a constrained polyethylene liner into a well-fixed, retained acetabular component at the time of revision are narrow. That’s largely due to concerns about the durability of the resulting acetabular construct. Now, thanks to a study by Brown et al. in the April 3, 2019 issue of JBJS, hip surgeons have some hard data about the long-term outcomes of this approach.
After reviewing 125 cases in which a constrained liner was cemented into a retained, osseointegrated acetabular component during revision THA, with a mean follow-up of 7 years, the authors found that:
- Survivorship free from revision for instability was 86% at 5 years and 81% at 10 years. The cumulative incidence of instability at 7 years was 18%.
- Survivorship free from aseptic acetabular component revision was 78% at 5 years and 65% at 10 years. The most common failure mechanism was dissociation of the constrained liner from the retained component.
- Harris hip scores (HHS) did not improve significantly after revision. This finding is consistent with prior research that shows better post-revision HHS scores in patients whose revisions include the entire acetabular component.
- Position of the retained cup did not affect implant survivorship or risk of dislocation.
The authors mention alternative strategies for reducing the risk of dislocation after revision THA, such as the use of large-diameter heads and dual-mobility constructs. Still, they conclude that this constrained-liner approach, in the setting of a relatively well-positioned acetabular component, is a viable and durable THA revision option, especially for those “with a compromised abductor mechanism, recurrent instability, [and] a well-fixed and well-positioned acetabular component, for whom an acetabular revision would not be tolerated.”
When discussing total joint replacement (TJR) with patients, I and most other surgeons who perform TJRs are invariably asked, “How long will my new hip last?’” or “Will I need to replace this new knee with another one if I live to be 90?” Although these important questions have essentially been studied since the implants and procedures were first developed, precise answers are still hard to come by. That’s largely because many factors can affect the longevity of an implant, including the implant material and design and the patient’s size/weight, activity level, and comorbidities. Also, many patients die before their joints wear out, and their data is often not captured accurately by researchers and registries. It is therefore difficult to give patients anything better than rough-estimate answers.
That is why I was interested to read two recently published systematic reviews in The Lancet. The reviews—one focused on knee replacement and the other on hip replacement—evaluated studies from six different non-US countries with robust joint registries in an effort to answer these “how long” questions. Based on the authors’ pooled analysis of registry data, the reviews found that:
- Nearly 60% of >215,000 hip replacements lasted 25 years, 70% lasted 20 years, and almost 90% lasted 15 years.
- The nearly 300,000 total knee replacements evaluated lasted even longer: 82% lasted 25 years, 90% lasted 20 years, and 93% lasted 15 years.
While these data are helpful, they do still not provide specific answers for the many individuals who may not be “standard” patients, and they do not take into account advances in implant designs and materials that have occurred over 25 years. However, as registry data becomes more ubiquitous and robust, especially in the United States with the growth of the American Joint Replacement Registry, I believe these questions will be answered with increased specificity for individual patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
You know you’re having a bad day at the gym when both your knees dislocate during a leg-press workout. That is what happened to a 44-year-old male recreational weight lifter who “locked out” both his knees while trying to press 1,100 lbs. This unusual case is described in the latest issue of JBJS Case Connector.
Knee joint dislocations are true emergencies because of the potential for concomitant neurovascular injury. This patient was transferred to a tertiary academic hospital for emergency closed reduction and application of knee-spanning external fixators. Although both tibiae were dislocated anteriorly, both lower extremities were neurovascularly intact.
One month after the initial injury, the external fixators were removed and the knees were placed in bilateral hinged braces. MRI performed shortly thereafter revealed tears of multiple ligaments and distal popliteus tendon tears in both knees. At 4 months postinjury, the patient underwent left-side ACL reconstruction, PCL reconstruction, FCL repair and reconstruction, popliteal reconstruction with allograft, and a popliteofibular ligament reconstruction. Seven months after that, he underwent similar procedures on the right side.
At the most recent postsurgical follow-up, 17 months after the initial injury, the range of motion in both knees was 0° to 130°, and the patient was able to participate in straight line running, squats, and cycling.
The authors emphasize that any locking of the knees results in 5° to 10° of hyperextension, which places an increased load across the ACL. Add to that the heavy weight and the abrupt increase in velocity at the extreme range of motion, and you have a recipe for serious injury. The authors conclude that “the risk of knee dislocation can be reduced by avoiding locking and hyperextension of the knees during any type of leg press or squatting exercise.”
For more information about JBJS Case Connector, watch this video featuring JBJS Editor in Chief Dr. Marc Swiontkowski.
As a journalist covering symposia at the 2019 AAOS Annual Meeting last week, I repeatedly heard the phrase “in my hands…,” referring to a surgeon’s individual experience with this or that technique. That got me to thinking about a research letter published in the March 6, 2019 issue of JAMA Surgery. This retrospective cross-sectional analysis of emergency department data revealed that the annual number of patients ≥65 years old presenting to US emergency departments with fractures associated with walking leashed dogs more than doubled during 2004 to 2017. Women sustained more than three-quarters of those fractures, and while the hip was the most frequently fractured body part, collectively, the upper extremity was the most frequently fractured region. Slightly more than one-quarter of those patients were admitted to the hospital.
The authors rightly pinpoint the “gravity of this burden”; the hip-fracture data alone are worrisome. And in a related online article by hand and wrist surgeons from Rush University Medical Center (titled “Doggy Danger”), the focus is on the many injuries that the human leash-holding apparatus can sustain. The authors of the JAMA Surgery research letter and the Rush authors offer common-sense advice for all us older dog walkers out there, including:
- Dog obedience training that teaches Bowser not to pull or lunge while on leash
- Selection of smaller dogs for older people contemplating acquiring a canine companion
- Holding the leash in your palm, not wrapping it around your hand
- Paying attention to where you walk, and being situationally aware (That means not texting while your dog is momentarily sniffing to see who peed on that post.)
- Selecting footwear that is appropriate for the terrain and environmental conditions during your walk
To these tidbits I would add finding a safe area where your dog can “be a dog” off-leash, preferably with other dogs and people. Socializing is good for both species, and most dog trainers and owners agree that “a tired dog is a good dog.”
The research letter states that a “risk-benefit analysis with respect to dog walking as an exercise alternative is essential,” and the authors do a concise job of quantifying fracture risk and suggesting risk-reduction strategies. The list of benefits from dog walking is too long to itemize here; suffice to say that the advantages run the gamut from physical to mental to spiritual. But let’s be safe and sensible out there. We owe it to our families (dogs included, of course) and to all those overworked orthopaedic trauma surgeons to stay on the sidewalks and in the forests and fields–and out of the ER.
JBJS Developmental Editor
The recent orthopaedic literature, including a 2017 JBJS study, provides substantial evidence that oral and intravenous tranexamic acid (TXA) are equivalent in their effectiveness at reducing blood loss after total hip arthroplasty (THA)—with oral administration being less expensive and more convenient. But what are the optimal doses and timing of oral TXA in the setting of THA?
The findings of a randomized controlled trial by Wang et al. in the March 6, 2019 issue of JBJS go a long way toward answering that question. The authors randomized 200 patients undergoing primary THA to 1 of 4 groups, with all patients receiving an intraoperative topical dose of 1.0 g of TXA and a single dose of 2.0 g of TXA orally at 2 hours postoperatively. In addition,:
- Group A received 1.0 g of oral placebo at 3, 9, and 15 hours postoperatively
- Group B received 1.0 g of oral TXA at 3 hours postoperatively and 1.0 g of placebo at 9 and 15 hours postoperatively
- Group C received 1.0 g of oral TXA at 3 and 9 hours postoperatively and 1.0 g of placebo at 15 hours postoperatively
- Group D received 1.0 g of TXA at 3, 9, and 15 hours postoperatively
The mean total blood loss during hospitalization was significantly less in Groups B, C, and D (792, 631, and 553 mL, respectively) than in Group A (984 mL). Groups C and D had lower mean reductions in hemoglobin than did Groups A and B. No significant between-group differences were observed regarding 90-day thromboembolic complications (there were none) or transfusions (there was only 1, in Group A), but the authors said “this study was likely underpowered for establishing meaningful comparisons concerning [those 2] outcomes.”
Although this study documented significantly lower total blood losses in patients who were managed with multiple doses of oral TXA postoperatively, additional studies are required to determine whether the 3-dose regimen is superior to the 2-dose regimen.
Based on available data, it appears that most arthroplasty surgeons in the United States (myself included) usually resurface the patella during total knee arthroplasties (TKAs). This strategy is supported by much of the orthopaedic literature, but there is no universal consensus on which approach is best. Internationally, surgeons in some countries resurface the patella <20% of the time.
Amid this debate, the March 6, 2019 JBJS study by Maney et al. utilizes the New Zealand Joint Registry to shine a little more light on the issue. After analyzing close to 60,000 primary TKAs performed by 203 surgeons, the authors found that patients who underwent knee arthroplasty by surgeons who “usually” (>90% of the time) resurfaced the patella had significantly higher patient-reported Oxford Knee Scores at both 6 months and 5 years postoperatively, compared to those who had their knee replacements performed by surgeons who “selectively” (≥10% to ≤90% of the time) or “rarely” (<10% of the time) resurfaced the patella. However, only 7% of the surgeons in the study fell into the usually-resurface category. That fact, along with the authors’ inability to account for possible confounding patient or surgeon factors, imparts some fragility to the study’s data. Just as (or even more) importantly, the authors did not find any differences in revision rates per 100 component years between the three resurfacing strategies, with >92% survival for all implants at 15 years postoperatively.
This study seems to support previously published data suggesting that resurfacing the patella yields functional outcomes that are at least as good as, if not slightly better than, those with not resurfacing the patella. Still, added costs and potential complications are associated with patellar resurfacing, and these results could also be used to support the strategy of surgeons who do not routinely perform that part of a total knee arthroplasty.
While we still don’t know the “best” strategy, this study adds further credence to the notion that there is not a “wrong” technique when it comes to resurfacing the patella, and surgeons should continue to use whichever technique they feel is best for individual patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media