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“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:

  1. Autonomy—coercion-free independence of thought and decision making
  2. Justice—the assurance that the burdens and benefits of new or experimental treatments are distributed throughout all groups
  3. Beneficence—the intent of doing good for the patient
  4. 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 Medicinethe 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.

RF Ablation for Knee Arthritis

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.

Durability of Constrained Liners in Revision THA

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.”

Doc, Will My New Joint Outlive Me?

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

Weight Training-Induced Bilateral Knee Dislocation

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.