Home in on Bone Health in Patients with Fragility Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from James Blair, MD, in response to a recent edition of the OrthoJOE podcast.
Geriatric hip fractures are among the fastest growing subset of injuries that orthopaedic surgeons treat. Often these injuries are the first objective signs of osteoporosis. While the surgical treatment of these fractures continues to improve, orthopaedic surgeons may be neglecting their role in triggering investigations into the underlying bone health of these patients.
A recent insurance database analysis by Sara Cromer, MD, presented at the Endocrine Society’s 2021 Annual Meeting, demonstrated a substantial drop in the use of bone-directed medications over the past decade, despite the rise in the number of osteoporotic-related fractures. It is unclear why this trend has occurred, but the main concern is that new diagnoses of osteoporosis are being overlooked.
This concern arose during a recent OrthoJOE podcast focused on distal radial fractures. OrthoEvidence Editor-in-Chief Dr. Mo Bhandari alluded to the confusion over who is responsible for bone-health intervention during treatment of a fragility fracture: the inpatient orthopaedic surgery team, the hospitalist, or the patient’s family physician or internist. “The thought is that someone is going to manage this,” Dr. Bhandari states. “Everyone is looking at everyone else, and it’s not happening.”
In fragility-fracture cases, JBJS Editor-in-Chief Dr. Marc Swiontkowski emphasized the importance of orthopaedic surgeons initiating investigations into their patients’ bone quality with evaluations of vitamin D, ionized calcium, and parathyroid and thyroid hormone levels. “We are failing miserably at this,” Dr. Swiontkowski laments, recalling seeing 3 elderly patients in a single day with a hip fracture that was preceded by a distal radial fracture a decade earlier–with no bone-health investigation ever performed at that time.
Initiatives like the American Orthopaedic Association’s (AOA’s) “Own The Bone” program try to raise awareness of our broader responsibility as orthopaedic surgeons when treating osteoporotic fractures such as those of the proximal femur, distal radius, and vertebrae. Drs. Bhandari and Swiontkowski strongly believe that the orthopaedic surgeon must claim ownership of their patients’ bone health, not necessarily by medically managing such cases, but by initiating a dialog with the patient’s primary care physician and/or rheumatologist/endocrinologist.
Click here to find out more about the AOA’s “Own The Bone” program.
James A. Blair, MD is the Director of Orthopaedic Trauma at the Medical College of Georgia at Augusta University and a member of the JBJS Social Media Advisory Board.
Targeted Muscle Reinnervation Helps Reduce—and Prevent—Pain in Amputees
Symptomatic neuromas have long been a problem for amputees, interfering with prosthetic comfort and causing residual pain that often requires treatment. During the last 15 to 20 years, surgeons have used targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures to improve symptoms from neuromas. In TMR, surgeons transfer a mixed or sensory nerve to a “target” transected motor nerve to prevent disorganized axonal growth. RPNI is a less complicated procedure during which the free nerve end is implanted into a denervated free muscle graft, again to decrease disorganized sprouting of axons.
Advances in amputee care at US military centers, driven largely by recent overseas conflicts, have shown anecdotally that TMR and RPNI prevent neuroma formation when used prophylactically during initial amputation, and that they also relieve pain when used as secondary treatment for existing neuromas. In the April 22, 2021 issue of The Journal, Hoyt et al. reviewed records from Walter Reed National Military Medical Center to evaluate changes in pain scores, symptom resolution, and frequency of complications when TMR and/or RPNI were utilized.
The authors analyzed 87 nerve interface interventions in 80 lower extremity amputations that had at least 6 months of follow-up. Fifty-nine of the procedures (68%) were done to treat symptomatic neuromas at a median of 6.5 years after amputation, while 28 procedures (32%) were done for primary prophylaxis. Hoyt et al. found that the sciatic nerve was most likely to develop symptomatic neuromas after amputations at or above the knee, while the tibial and peroneal nerve distributions were most commonly symptomatic after amputations distal to the knee. TMR was utilized alone in 85% of the cases, and surgeons used RPNI most frequently to prevent pain in the sural and saphenous nerves.
Overall, symptom resolution after all procedures was 92% at the final follow-up. VAS pain scores improved from 4.3 to 1.7 points in the delayed-treatment group and did not vary by amputation level. The final mean pain score in the primary-prophylaxis group was 1.0 ±1.9. There were no significant differences in pain outcomes between the primary and delayed groups, but 6 patients in the delayed cohort required revision for residual limb or phantom limb pain. In patients with transtibial amputations, failure to address an asymptomatic tibial nerve during delayed TMR resulted in an increased risk of revision surgery.
Although retrospective in nature, this study shows some encouraging early data to support the primary and secondary use of TMR/RPNI in amputee care. More research is required to determine whether these results in wounded warriors can be replicated in a civilian amputee population.
Click here for a Commentary on this study by Ann R. Schwentker, MD.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Low Adherence to Open-Fracture Antibiotic Guidelines
The prompt administration of prophylactic antibiotics is considered a critical component of open-fracture management. In 2011, the Eastern Association for the Surgery of Trauma (EAST) recommended updates to traditional antibiotic administration, including gram-positive coverage for Gustilo Type-I and Type-II fractures, the addition of gram-negative coverage for Type-III, and additional penicillin for the presence of fecal or clostridial contamination. Concerns regarding the side effects of antibiotics, along with changing patterns in bacteria resistance, have led many treating physicians to consider alternative antibiotic choices.
In a recent JBJS article, Lin et al. report on the level of adherence to open-fracture antibiotic guidelines (both traditional and EAST recommendations), analyzing data collected as part of 2 large, ongoing, multicenter trials. They also evaluated the association of Gustilo type, wound contamination, and multifracture injuries with antibiotic choice and duration.
Included were 1,234 patients from 24 medical centers in the US and Canada, all of whom received antibiotics on the day of admission. While cefazolin monotherapy was the most commonly prescribed regimen (53.6%), 54 different combinations of prophylactic antibiotics were prescribed. Lin et al. found moderate adherence to traditional antibiotic treatment guidelines for Gustilo Types-I and II fractures and low adherence for Type-III, and less-than-optimal compliance with the EAST recommendations: 31% of Gustilo Type-I and Type-II fractures received gram-negative coverage, and 54.9% of Type-III fractures did not.
The authors offer many plausible reasons for low compliance, including increased incidence of methicillin-resistant S. aureus infections, concerns regarding the nephrotoxicity of aminoglycosides, and the more frequent use of intraoperative topical antibiotics.
The median duration of antibiotic use following wound closure in this study was 2 days. The authors note that the most widely recommended duration in the literature is 3 days after wound closure, which they add, contradicts the <24 hours recommended by the EAST guidelines (for Type-III fractures, discontinuation within 72 hours post-injury or 24 hours after soft-tissue coverage).
The study provides helpful insight into the sometimes contradictory and confusing guidelines for open-fracture antibiotic prophylaxis and the variations that exist in current practice patterns. It also begs the question: is it time for a stringent new look at the guidelines and more high-quality research into which practices help ensure the best patient outcomes and the most sensible antibiotic stewardship?
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Proximal Humeral Fractures: More Data on Nonunion Risk
Proximal humeral fractures tend to occur in a bimodal distribution, namely, in younger, primarily male patients and in older (>65 years of age), primarily female patients. In the latter population, such fractures are often related to low bone density, and we in the orthopaedic community now recognize the imperative to evaluate at-risk individuals through measures such as DXA scanning and laboratory assessments of bone health in order to institute appropriate monitoring and pharmacotherapy.
Regarding the treatment of these fractures, several large trials have demonstrated that, for select fracture patterns, nonsurgical care results in clinical and functional outcomes that are equal to or better than surgical care with open reduction and internal fixation or arthroplasty. The question for treating clinicians is: are there proximal humeral fracture patterns that have higher rates of complications (chiefly nonunion) following nonsurgical care?
In a retrospective study reported in JBJS, Goudie and Robinson evaluated the rate of nonunion among patients who were treated nonoperatively for a proximal humeral fracture at their regional trauma center in the UK. They also sought to develop and validate a prediction model to assess nonunion risk, measuring the effect of 19 patient demographic and radiographic variables on healing.
Overall, 231 (10.4%) of the 2,230 included patients experienced nonunion. Among those with valgus angulation of the humeral head (395 patients), the nonunion prevalence was <1%, and none of the other variables evaluated were associated with increased risk of nonunion in a multivariable analysis. However, among the 1,835 patients with neutral or varus angulation of the head, the prevalence of nonunion was 12.4%, and decreasing head-shaft angle, increasing head-shaft translation, and smoking were independently predictive of nonunion.
Important to note is the residual pain and diminished function that often accompanies nonunion. Still, the authors rightly point out that “surgery aimed solely at preventing nonunion exposes patients to the risk of other complications that are not encountered with nonoperative treatment.” But, based on these findings about fracture morphology, they conclude that “medically fit patients with translated and/or angulated fractures should be counseled about smoking cessation and considered for surgery to avoid the debilitating effects of subsequent nonunion.” Patients with these fracture characteristics deserve closer scrutiny in our efforts to provide the best treatment for proximal humeral fractures.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Click here for a JBJS Clinical Summary on proximal humeral fractures.
Machine Learning Algorithm May Predict Postfracture Infection
Infection after surgery to treat a tibial shaft fracture can have devastating consequences, with significant associated costs and burdens. Although research has identified general risk factors that increase the likelihood of infection (including complexity of injury and fracture patterns and patient-related factors such as smoking and diabetes), predicting risks for individual patients remains difficult.
In a recent study in The Journal, investigators from the Machine Learning Consortium reported on an algorithm they developed to predict the risk of infection in specific patients who receive operative treatment for a tibial shaft fracture. To develop their model, the researchers used high-quality data from the SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) and FLOW (Fluid Lavage of Open Wounds) randomized controlled trials.
The Australian researchers “trained” 5 machine learning algorithms and tested them against various performance measures to evaluate 1,822 fractures, including 170 (9%) that developed an infection. Based on predictive performance in that derivation portion of the study, 3 algorithms were validated and 1 prediction model was found to be superior. In that model, Gustilo-Anderson Type IIIA and IIIB fractures, age, AO/OTA type 42C3 fractures, crush injuries, and falls were the strongest predictors of infection.
Researchers have made their model available in an online, open-access prediction tool. Although the authors emphasize that this preliminary tool is intended for research and not for widespread clinical use, I think it has profoundly positive potential. Being able to risk-stratify a patient with a tibial shaft fracture at or near the time of admission could allow surgeons to closely monitor—and intervene sooner—in fracture cases at risk for infection, thereby possibly preventing devastating complications. This prediction tool certainly needs external validation prior to “prime-time” adoption, but when it comes to exploring artificial intelligence and machine learning in orthopaedics, the future is now.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Long-Term Patient Follow-up: Not Easy but Worth the Effort
Longer-term follow-up of orthopaedic patients is instrumental to research and the advancement of patient care. One simply cannot understand the impact of surgical decision-making and technique without examining the patient, assessing images, and evaluating function over time. However, in all areas of orthopaedic surgery, we struggle to get patients to return for evaluation when they feel mostly recovered. If patients are doing well in terms of pain and function, they may understandably see little or no clinical imperative to return for follow-up. This is particularly true among younger, more active patients—the primary group involved in higher-energy trauma and those who are perhaps the most resistant to follow-up visits.
Conversely, the orthopaedic research community and the journals that publish their findings have a widely embraced expectation of 1-year minimum follow-up. Agel et al. closely scrutinize this expectation/reality disconnect in a recent JBJS report. Reviewing 293 patients treated surgically for acute orthopaedic trauma injuries (mean age, 47.5 years), the authors observed a 29% rate of 1-year follow-up. Evaluating potential risk factors for patients not following up, they identified tobacco use, final appointment status (follow-up as needed vs request to return), isolated vs. multiple fractures, and distance from the trauma center as significant predictors.
While the authors ultimately concluded that a 1-year follow-up requirement “may not be feasible,” I think treating physicians can play a critical role in improving follow-up, even in trauma cases, where a physician-patient relationship may not exist prior to treatment. In addition to cementing a relationship with all our patients, we should clearly articulate that returning for evaluation will help subsequent patients with similar injuries or conditions.
In their “Author Insights” video about this study, co-authors Conor P. Kleweno, MD and Avrey A. Novak, MD cite new technologies for contacting patients for follow-up evaluations. I believe that, given convenient opportunities to do so, many patients will want to help us improve care for those who come after them.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
WALANT Surgery Works for Ankle Fractures
OrthoBuzz previously covered WALANT (wide awake, local anesthesia, no tourniquet) surgery, and we very recently featured a JBJS study about treating ankle fractures in a limited-resource environment. These 2 concepts unite in a JBJS study by Tahir et al., which reports on WALANT surgery for ankle fractures in Pakistan.
WALANT surgery has enjoyed increasingly broad dissemination throughout the world since its popularization by Canadian hand surgeon Don Lalonde. Considering its origins, WALANT has been adopted most enthusiastically by the hand-surgery community, but it has been applied successfully to other anatomic regions. WALANT principles are particularly relevant in settings where anesthetic resources and expertise may be limited, such as hospitals where monitoring equipment that helps ensure safe general anesthesia is not readily available.
Tahir et al. used WALANT during open reduction/internal fixation (ORIF) in 58 patients (average age of 47 years) with a distal fibula fracture; 62% of those fractures were OTA-classified as 44C2. Among the excellent results in this cohort were a mean intraoperative VAS pain score of 1.24 and a mean operative time of <1 hour. These findings point to the potential for safely using WALANT techniques during ORIF of other fracture types.
The authors emphasize, however, that “each patient should be individually assessed by the operating surgeon,” not only for injury characteristics that contraindicate WALANT, such as substantial swelling, but also for anxiety and psychological disorders. Consequently, Tahir et al. recommend that surgeons undertaking WALANT procedures have a backup anesthetist available so they can convert to general anesthesia in cases of patient anxiety.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Sustainable Trauma Care in Low-Resource Settings: How Can We Help?
Orthopaedic colleagues who live and practice in low-resource areas around the world have clearly voiced that they want support from better-resourced partners. But such efforts must be sustainable, a key point emphasized by Woolley et al. in their thought-provoking 2019 JBJS “What’s Important” essay regarding orthopaedic care in Haiti. In contrast to “medical missions” offering short-term assistance for a small number of patients, longer-term systemwide gains come from partnerships focused on education and training that acknowledge the central role of local orthopaedic practitioners in addressing the ongoing needs of their patients.
Along those lines, Agarwal-Harding et al. describe a 3-phase pathway for improving ankle-fracture management in sub-Saharan Malawi in their recent JBJS report. In the first 2 phases, the local knowledge base and treatment strategies were assessed. (Greater than 90% of orthopaedic trauma care in the country is provided by nonphysician “clinical officers,” and most ankle-fracture management in Malawi is nonoperative because there is only about 1 orthopaedic surgeon per 1.9 million Malawians). A team of Malawian and US faculty then designed and implemented an education course that reviewed ankle anatomy, fracture classification, and evidence-based treatment guidelines. From that arose standardized protocols to improve fracture-care quality and safety in the face of limited resources.
While these protocols were unique to the Malawian context, I am convinced that similar interventions can be adapted for other low-resource environments—as long as local clinicians are part of the process. With such a flexible and sustainable program in place, efforts can then be directed toward the advancement of surgical skills and development of cost-effective supply chains. We should all support such efforts worldwide, recognizing that the burden of musculoskeletal trauma is a public health issue warranting collaborative solutions with lasting impact.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Click here for a related OrthoBuzz post about trauma care in Malawi.
Life Expectancy Informs Choice of Hemi Implant after Femoral Neck Fracture
Predicting life expectancy is not an exact science. But estimating the remaining years of life in elderly patients with a femoral neck fracture may help orthopaedists determine whether to use unipolar or bipolar hemiarthroplasty components when surgically managing that population. So suggest Farey et al. in the February 3, 2021 issue of The Journal of Bone & Joint Surgery.
The relevant “magic number” for life expectancy after femoral neck fracture is 2.5 years. The authors arrived at that number by performing statistical analyses on nearly 63,000 cases of femoral neck fractures treated with either modular unipolar or bipolar hemiarthroplasty. Patients were in their early 80s on average at the time of surgery. The researchers focused on revision rates because reoperations in this vulnerable group of patients typically yield poor results.
There was no between-group difference in overall revision rate within 0 and 2.5 years after the procedure. However, unipolar hemiarthroplasty was associated with a higher overall revision rate than bipolar hemiarthroplasty beyond 2.5 years after surgery (hazard ratio [HR], 1.86).
Farey et al. also drilled down into reasons for revision and found that unipolar prostheses had a greater risk of revision for acetabular erosion, particularly in later postoperative time periods. Conversely, bipolar hemiarthroplasty was associated with a higher risk of revision for periprosthetic fracture, which the authors surmise might have arisen from the greater range of motion (and therefore activity levels) permitted by bipolar implants.
Although the authors did not perform a formal cost-benefit analysis related to this dilemma, they observed a nearly $1,000 USD price difference between the most commonly used bipolar and unipolar prostheses. Farey et al. therefore propose that the more expensive bipolar prosthesis may be justified for patients with a life expectancy beyond 2.5 years, but that the unipolar design is justified for patients with a postoperative life expectancy of ≤2.5 years.
Click here to listen to a 15-minute OrthoJOE podcast about this topic, featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski and OrthoEvidence Editor-in-Chief Dr. Mo Bhandari.
Click here to see a 3-minute Video Summary of this study.
Click here to read a JBJS Clinical Summary comparing total hip arthroplasty with hemiarthroplasty for displaced femoral neck fractures.
Surgical-Technique Videos Focus on Pediatric Fractures
Many orthopaedic surgeons who take emergency-department or trauma call are confronted with a pediatric patient presenting with a fracture. However, very few of those orthopaedists are pediatric subspecialists. In fact, Geisinger researchers recently reported that the median number of pediatric orthopaedists per state in the US is only 23 (range 0 to 134).
To address these demographic realities, JBJS Essential Surgical Techniques has launched a video-based, point-of-care resource to help any orthopaedic surgeon manage the most common pediatric fractures with the highest level of quality, helping ensure excellent outcomes for young patients and their parents. Most of the authors of these pediatric-focused procedural videos are members of CORTICES—a collaboration of pediatric orthopedic surgeons dedicated to improving the management of emergent orthopedic conditions through education, research, and development of optimal care guidelines.
Here are links to the 5 already-published video articles in this series:
- Open Reduction and Suture Fixation of Acute Sternoclavicular Fracture-Dislocations in Children
- Elastic Stable Intramedullary Nailing of Pediatric Tibial Fractures
- Closed Reduction of Pediatric Distal Radial Fractures and Epiphyseal Separations
- Open Reduction and Pin Fixation of Pediatric Lateral Humeral Condylar Fractures
- Elastic Intramedullary Nailing of Pediatric Both-Bone Forearm Fractures
Upcoming videos in this special series will cover the following 5 topics:
- Screw Fixation of Pediatric Proximal Tibial Tubercle Fractures
- Reduction and Internal Screw Fixation of Transitional Ankle Fractures
- Flexible Intramedullary Nailing of Pediatric Femur Fractures
- Intramedullary Fixation of the Ulna for Monteggia Fracture Management
- Open Reduction and Internal Fixation of Pediatric Medial Epicondyle Humerus Fractures
JBJS Essential Surgical Techniques is the premier online journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, and utilizing video to optimize the educational experience, thereby enhancing patient care.
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