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More Progress in Preventing Secondary Fragility Fractures

ownbone_logo-rHow well do fracture liaison services (FLSs) work in terms of patients who’ve had a fragility fracture receiving a recommendation for anti-osteoporosis treatment? Very well, according to findings from an analysis of more than 32,000 patients by Dirschl and Rustom in the April 18, 2018 edition of The Journal of Bone & Joint Surgery.

A fracture liaison service is a coordinated, multidisciplinary model of care designed to reduce the risk of future fractures among patients who’ve sustained a primary fragility fracture. (Click here for another recent JBJS article about the FLS model.) The American Orthopaedic Association (AOA) has been a major proponent of the FLS model, and it is a cornerstone of the AOA’s “Own the Bone” national quality-improvement program.

Dirschl and Rustom found that between 2009 and 2016, at 147 sites participating in an FLS through Own the Bone, 72.8% of 32,671 patients initially evaluated for a fragility fracture received a recommendation for anti-osteoporosis treatment. That’s a vast improvement compared with previous reports that indicate only 20% of patients with a fragility fracture received either an osteoporosis evaluation or treatment. In this current study, a sedentary lifestyle and having a parent who had sustained a hip fracture were the patient factors associated with those most likely to receive a recommendation for treatment.

OrthoBuzz editors were surprised to read that anti-osteoporosis treatment was initiated in only 12.1% of the patients in this study. When we asked JBJS Editor-in-Chief Marc Swiontkowski, MD for a further explanation, he noted that the study captured data only from the initial post-fracture encounter between patients and FLS clinicians. The percentage of patients initiating treatment would have been much higher, he said, if the data had included those who followed up their initial FLS evaluation with a primary care physician. He also remarked that some people are dissuaded from taking an FDA-approved prescription anti-osteoporosis medication by the disproportionate focus on side effects that patients read in social media and the lay press. And there are some patients for whom prescription anti-osteoporosis drugs are truly contraindicated.

But with an estimated 2 million people in the US sustaining a fragility fracture each year, these results indicate substantial progress in practices that will prevent secondary fractures.

Click here for a listing of upcoming Own the Bone events.

Childhood Toe-Walking: Usually a Transient Condition

Toe Walking for OBuzzParenting is a lot like medicine. Parents seek to “fix” their children, and physicians seek to “fix” their patients. However, sometimes the best “fix” is to observe closely, do nothing, and let nature take its course. That’s the main conclusion of the study by Engstrom et al. in the April 18, 2018 edition of JBJS. The authors set out to document the natural history of idiopathic toe-walking to determine how often the condition resolves without intervention.

After analyzing a cohort of more than 1,400 children, the authors found that 63 (5%) had been toe-walkers at some point as a toddler—but that almost 80% of those children spontaneously ceased being toe-walkers by the time they were 10 years of age.  However, the authors found that children with ankle contractures before age 5 were unlikely to spontaneously cease toe-walking and would benefit from early surgical intervention. This study also demonstrated a correlation between neurodevelopmental comorbidities and toe-walking. Although 4 of the 8 children who still toe-walked at 10 years of age had received a neurodevelopmental diagnosis between the ages of 5.5 and 10 years, the authors state that “even in this subgroup of children, the idiopathic toe-walking seems, for the majority of children, to be a transient condition.”

Taken as a whole, this Level-I prognostic study provides relatively clear treatment pathways for clinicians and parents to follow when a child presents with toe-walking. The findings can be used to help calm the fears of parents regarding their child’s development while also giving surgeons the confidence to treat the majority of these children with observation unless there is a contracture of the calf musculature.

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

Fifth Anniversary of Boston Marathon Bombing

SpecialReportII-Cover-FinalOn the eve of the 2018 Boston Marathon, we wish all the participants a safe run tomorrow. And we remember all those who are still experiencing the aftermath of the 2013 Marathon Bombing.

Not a single person who reached a Boston hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients. Click here to download the report for free.

We  thank the many people whose dedication to disaster-preparedness helps ensure that the 2018 and future Boston Marathons will go on.

Outcomes from Shoulder Fusion Are Durable, Not Spectacular

Shoulder Arthrodesis for OBuzzGlenohumeral arthrodesis is a salvage operation, so most patients and surgeons considering this option don’t have expectations of spectacular functional outcomes. Improving stability and relieving pain are usually the main goals. In the April 4, 2018 edition of The Journal of Bone & Joint Surgery, a retrospective study by Wagner et al. sheds light on long-term results of this procedure (mean follow-up of 12 years) and the patient and surgical factors that might improve or worsen outcomes.

The authors reviewed electronic and paper medical records of 29 cases of glenohumeral arthrodesis performed between 1992 and 2009. They also analyzed patient questionnaires, which included DASH, SSV, and SF-36 scoring instruments.

All patients reported improvement in pain at the time of their latest postoperative follow-up. However, 12 patients (41%) had postoperative complications, including nonunions, fractures, and deep infections. Eleven patients (38%) required additional post-arthrodesis surgical procedures. The mean postoperative shoulder position was 60° in flexion and 13° in external rotation.

The authors identified the following correlations between patient/surgical factors and outcomes:

  • Patients with a history of brachial plexus injuries had worse clinical and functional outcomes.
  • Patients with shoulders fused in abduction and flexion of >25° had better shoulder function but a slightly higher risk of peri-fixation fracture.
  • There were no significant outcome differences between procedures that used plate-and-screw and screw-only fixation. However, incorporation of the acromion in fixation was strongly associated with a lower risk of nonunion.

The authors conclude that despite the limitations of this complex salvage procedure, “its ability to relieve pain and to maintain reasonable upper-extremity function in select patients should not be overlooked.”

Does Residency Prepare Surgeons for Early Orthopaedic Practice?

Shoulder arthroscopy for OBuzzOne goal of an orthopaedic surgery residency is to prepare residents for the procedures they will perform when they are attendings. Yet, until the retrospective cohort study by Kohring et al. in the April 4, 2018 issue of The Journal, it remained unclear how similar a resident’s surgical case mix was compared to the cases attendings saw in early practice.  Kohring et al. used data from both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) to compare the types of procedures residents performed between 2010 and 2012 to the cases junior attendings submitted for the ABOS Part II examination between 2013 and 2015. The authors then categorized the cases by CPT codes and split them into adult and pediatric categories to allow for further comparison.

Here are a few interesting findings from the study:

  • More than half of all adult and pediatric procedures performed during residency and by early-career attendings fell within the top 10 CPT code categories.
  • Knee and shoulder arthroscopy were the most commonly performed cases in adults during both residency and early practice.
  • Residents take part in total knee and total hip arthroplasties much more frequently than do attendings in early practice.
  • Attendings in early practice treat more than twice the number of proximal femur fractures than do residents during residency.
  • Residents are exposed to a much higher rate of spinal fusion cases than are seen by early-practice attendings.

Although the authors conclude that the “similarity between residency and early practice experience is generally strong,” this study highlights some of the disparities between the two cohorts, and these findings may inform further research aimed at improving training for orthopaedic surgeons. By themselves, however, these results should not be used to change the experience residents have during their training. The authors mention the limitations inherent when comparing these two cohorts, and I can testify that my clinical practice has evolved tremendously in the 3 years since I started as an attending.

Furthermore, with more than 90% of orthopaedic residents going on to complete a subspecialty fellowship immediately after residency, it is safe to say that the degree of similarity between residency and attending case experience will vary from surgeon to surgeon.

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

April 12 Webinar – Managing Osteoarthritis: Moving from Volume to Value

April Webinar SpeakersAccording to the CDC, in 2013, the total national arthritis-related medical care costs and earnings losses among adults were $303.5 billion, or 1% of the 2013 US Gross Domestic Product.

One response to statistics like that is the notion of “value-based health care.” How far has the orthopaedic community moved from a volume/fee-for-service-based model to one in which patients achieve the best possible musculoskeletal outcomes, payers expend the fewest possible dollars, and providers throughout the episodes of care are fairly compensated for their skill and compassion?

On Thursday, April 12, 2018 at 8:00 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar that will answer these thorny questions by discussing the cost drivers behind the problem, where arthritis management stands currently, and where the value-based care bandwagon is heading.

Kevin Shea, MD, an expert in developing clinical practice guidelines, will discuss the crucial differences between “irrational variation” and “rational, patient-centered variation.”

Antonia Chen, MD, director of arthroplasty research at Harvard Medical School, will demystify the many attempts to measure and improve the quality of joint replacement and will address quality and value in the nonoperative management of osteoarthritis.

Gregory Brown, MD, a Tacoma, Washington-based surgeon specializing in knee reconstruction, will peer into the future of health insurance, patient empowerment, and robust orthopaedic registries.

Moderated by Douglas Lundy, MD, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.

Register Now.

Which Pathology Comes First—Bone Loss or Fatty Infiltration of Rotator Cuff?

Fatty Infiltration for OBuzzThe relative roles of bones and muscles in joint pathologies are often difficult to tease apart. In the March 7, 2018 issue of The Journal, Donohue et al. report findings from their attempt to identify associations between preoperative fatty infiltration in rotator cuff muscles and glenoid morphology among 190 shoulders that underwent total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis.

The painstaking analysis included orthogonal CT images to determine fatty infiltration, joint-line medialization assessments, direct measurements of glenoid version, and grading of glenoid morphology (from A1 through C2) using a modified Walch classification. Here’s what Donohue et al. found:

  • High-grade posterior rotator cuff fatty infiltration was present in 55% of the 38 glenoids classified as B3, compared with only 8% fatty infiltration in the 39 A1-classified glenoids.
  • Increasing joint-line medialization was associated with increasing fatty infiltration of all rotator cuff muscles.
  • Higher fatty infiltration of the infraspinatus, teres minor, and combined posterior rotator cuff muscles was associated with increasing glenoid retroversion.
  • After the authors controlled for joint-line medialization and retroversion, B3 glenoids were more likely than B2 glenoids to have fatty infiltration of the supraspinatus and infraspinatus.

The authors say these findings “support the idea that there is a causal association between rotator cuff muscle fatty infiltration and B3 glenoid morphology,” but they are quick to add that “from this study we cannot conclude [whether] these patterns of rotator cuff muscle fatty infiltration precede the progression of bone pathology, or vice versa.” Either way, these findings may inform patient-surgeon discussions about TSA, because both glenoid morphology and rotator cuff muscle quality are factors in glenoid-component longevity.

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.