As Sarac et al. note in the latest JBJS fast-tracked article, the phrase “elective procedure” is ambiguous, even though it is supposed to identify procedures that are being postponed to help hospitals cope with the COVID-19 pandemic. Guidelines from the Centers for Disease Control and Prevention (CDC) say that operations for “most cancers” and “highly symptomatic patients” should continue, but that leaves much of the ambiguity unresolved. What constitutes an elective procedure in orthopaedics at this unusual time remains unclear.
To help clarify the situation, the authors summarize guidance issued by states and describe the guidelines currently in use for orthopaedic surgery at their institution, The Ohio State University College of Medicine.
Here are the state-related data collected by Sarac et al., as of March 24, 2020:
- 30 states have published guidance regarding discontinuation of elective procedures; 16 of those states provide a definition of “elective” or offer guidance for determining which procedures should continue to be performed.
- 5 states provide guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly permit trauma-related procedures, and 4 states recommend against performing arthroplasty.
- 10 states provide guidelines permitting the continuation of oncological procedures.
In the Buckeye State, the Ohio Hospital Association asked each hospital and surgery center to cancel procedures that do not meet any of the following criteria:
- Threat to a patient’s life if procedure is not performed
- Threat of permanent dysfunction of an extremity or organ system
- Risk of cancer metastasis or progression of staging
- Risk of rapid worsening to severe symptoms
Mindful of those criteria, individual surgical and procedural division directors at the authors’ university developed a list of specific procedures that should continue to be performed. Respective department chairs approved the lists, which were then sent to the hospital chief clinical officer for signoff.
The authors tabulate the orthopaedic procedures that continue to be performed at their institution as of March 25, 2020, but they are quick to add that even this list is not without ambiguity. For example, surgery should continue on “select closed fractures that if left untreated for >30 days may lead to loss of function or permanent disability,” but that requires surgeons to judge, in these uncertain and fluid times, which fractures necessitate fixation in the short term.
Sarac et al. emphasize that such lists, however specific they are today, are likely to change as demands on hospitals shift. They suggest that as the pandemic evolves, a further classification of procedures into 2 time-based categories might be helpful: (1) those that need to be performed within 2 weeks and (2) those that need to be performed within 4 weeks. Sarac et al. also remind orthopaedic surgeons to provide patients waiting for surgery that has been postponed with information regarding safe and effective methods of managing their pain.
JBJS has already fast-tracked an article by Mi et al. about the best way to manage patients who have a bone fracture as well as COVID-19. The latest fast-tracked COVID-19 article from JBJS comes from Portuguese authors Rodrigues-Pinto et al. It provides an exquisitely detailed protocol for operating room set-ups and staff workflows when treating surgical patients who are COVID-19-positive, with an emphasis on the specifics required for trauma and orthopaedic surgery.
The authors describe a 5-zone operative complex, as shown in the Figure above. Most of the details from Rodrigues-Pinto et al. explain precautionary procedures to be taken in Zones 1 and 2 and Zones 3 and 4, areas preceding and following the operating room.
For Zone 3, the OR itself, the authors recommend a portable HEPA filtration system with a high frequency of air changes to rapidly reduce the viral load within the OR. Another in-the-OR tip for trauma and orthopaedic surgical procedures is to use power tools (such as electrocautery, bone saws, reamers, and drills) sparingly, and to set their power levels as low as possible. That’s because such tools release aerosols, which increase the risk of virus spread. Suction devices to remove smoke and aerosols should also be used during surgical procedures on COVID-19 patients.
For more than 40 years, orthopaedic trauma surgeons have been interested in this fairly common fracture combination, which is often seen in polytrauma patients. We have long hypothesized that much of the energy that fractures the femoral shaft is dissipated, leaving many ipsilateral neck fractures nondisplaced and difficult to recognize on plain radiographs.
But the consequences of missing a femoral neck fracture can be devastating. For example, because the neck fracture pattern is often vertical (Pauwels type III), the risk of displacing the neck fracture during intramedullary nailing is very high. Achieving reduction and fixation of a displaced neck fracture near an intramedullary nail—either intraoperatively or postoperatively—is extremely challenging.
Because of these issues, some authors recommend a thin-cut CT series to identify nondisplaced ipsilateral neck fractures preoperatively, and this protocol has been shown to significantly reduce the delay in identifying such fractures. In the February 19, 2020 issue of The Journal, Rogers et al. from UTHealth in Houston show that even with thin-cut CT, the crack can be missed. These authors added to the protocol limited-sequence MRI that identifies these fractures with very high sensitivity and takes <10 minutes to perform.
In this study, among 39 acute, high-energy femoral shaft fractures, the authors identified 4 ipsilateral neck fractures with MRI that were not seen on CT. Despite exhibiting polytrauma, 89% of all indicated patients in this study were evaluated preoperatively with the limited-sequence MRI protocol, including those in traction and those treated initially with external fixation.
The findings from this study should prompt trauma surgeons practicing in high-volume centers to develop similar MRI protocols. It may also be possible to develop such protocols in lower-volume centers, but in those settings it is especially incumbent on the surgical team to recognize that this fracture combination occurs in a fairly high percentage of cases and to carefully scrutinize plain radiographs and consider thin-cut CT scanning of the ipsilateral hip. In addition, the potential for an ipsilateral nondisplaced femoral neck fracture should trigger increased use of fluoroscopy during intramedullary nailing of shaft fractures, so that concomitant neck fractures can be recognized and stabilized with screws before they become displaced.
Marc Swiontkowski, MD
Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.
Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.
Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.
On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.
It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.
Marc Swiontkowski, MD
Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.
In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.
At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.
Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
- Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.
Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures:
- “Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
- How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
- Immobilization after Fixation of Distal Radial Fractures
- Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
- Fixation Costs for Distal Radial Fracture
- Plate–Tendon Contact: How Important Is It?
Innovation in medicine has brought innumerable improvements in patient care. For example, as late as the Vietnam War era, femoral shaft fractures were frequently treated with prolonged periods of traction—until intramedullary rods gained popularity because they helped patients mobilize soon after the injury. Similarly, negative-pressure wound therapy (NPWT) gained popularity in the 1990s because it was so helpful with treating open wounds in orthopaedics. NPWT has been a mainstay in the treatment of Wounded Warriors with blast injuries during the last 18 years of conflicts in Afghanistan, Iraq, and other war zones. But medical innovations such as NPWT often come with a high cost, which has made access to commercial NPWT unfeasible in many low-income, resource-challenged countries. Sadly, those places are also home to many patients who sustain devastating soft-tissue injuries.
In the November 20, 2019 issue of JBJS, Cocjin et al. from the Philippines report results from a randomized controlled trial that compared 7-day outcomes from a commercially available NPWT system to those from an innovative, low-cost system that the authors developed locally and have been using at their institution since the mid-2000s. This home-grown system consists of an aquarium pump converted into a reusable vacuum source, along with basic hospital supplies such as surgical gauze, tubing, and plastic food wrap. The authors also compared the cost of the two systems.
For most of the measured clinical outcomes, Cocjin et al. found that their innovative NPWT system was noninferior to the commercially available system. It was actually better (but not significantly so) in terms of time of application, pain during dressing changes, and wound-contraction percentages. There were no complications with either system, and the system made from the aquarium pump and hospital supplies cost 7 times less than the commercial device ($63.75 compared to $491.38 USD). The converted aquarium-pump system can be used up to 20 times, making its per-use cost as low as $3.
Innovation is vital to advancing orthopaedics. But we must also remember that low-cost innovation is equally important for a large portion of the worldwide patient and provider population that is resource-constrained. I applaud Cocjin et al. for sharing their locally developed innovation with the wider orthopaedic community. Although further validating studies are needed, this “homemade” NPWT system has the potential to bring to a large portion of the world a cost-effective alternative to a wound-management technique that has become a mainstay in more affluent settings over the past 2 decades.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
According to the orthopaedic literature, the risk of vascular injury during internal fixation of a proximal femoral fracture is low. But applying the findings from an anatomical analysis by Jaipurwala et al. in the November 6, 2019 issue of The Journal of Bone & Joint Surgery could help minimize that risk even further.
The authors examined lower-limb CT angiograms of 47 patients (mean age 69) who had the scans performed for reasons other than a femoral fracture. They then measured the distance from the tip of the greater trochanter to the profunda femoris artery and its perforators within 5 mm of the medial femoral shaft, along the length of typical placement of dynamic hip screws used for fixation of proximal femoral fractures. (The authors assumed the use of a 4-hole, 78 mm plate or a 6-hole, 110 mm plate.)
All 47 patients had 2 vessels within 5 mm of the medial femoral shaft along the line of presumed dynamic hip screw insertion. Noting that these vessels could be damaged by reduction instruments or during drilling and plate-screw insertion during actual cases of femoral-fracture fixation, Jaipurwala et al. make the following suggestions:
- Avoid or take special care when drilling or inserting screws along the femoral shaft from 110 to 120 mm from the tip of the greater trochanter in women and from 120 to 130 mm in men.
- If possible, avoid inserting a screw in the fourth hole of a 4-hole dynamic hip screw plate or inserting a screw in the fourth and fifth holes of a 6-hole plate.
The authors emphasize that these suggestions are based on measurements taken from patients who did not have a hip fracture and that “a femoral fracture may potentially alter local anatomy because of swelling and damage to surrounding structures.” But they conclude that the risk of vascular injuries in patients with a proximal femoral fracture would be further reduced if surgeons took these findings into account during operative planning and execution of hip-fracture fixation.
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 Paul E. Matuszewski, MD.
A recent issue of The New England Journal of Medicine published the results from a large, multicenter randomized trial comparing the outcomes of hemiarthroplasty versus total hip arthroplasty (THA) to treat displaced femoral neck fractures in ambulatory adults.
The HEALTH investigators enrolled 1,495 patients in the study, and 85.1% of those patients had complete data for analysis after 2 years. The researchers found no significant differences between the groups with regard to the primary outcome—secondary hip procedures (7.9% in the THA group vs 8.3% in the hemi group). The risk of secondary hip procedures during the first year was higher in the THA group, but the hemiarthroplasty group had a higher risk of secondary procedures in the second year. Open/closed reductions of hip dislocations were the most common secondary procedures among the THA group, and revision to THA was the most common secondary procedure in the hemiarthroplasty group. The THA group had slightly better WOMAC scores, but the difference was not within a clinically significant range. There were no between-group differences noted in other patient-reported outcomes.
The HEALTH investigators followed these patients for only two years, which is notably the standard for many orthopaedic studies, but this short follow-up limits the practical application of these findings. The authors note that after the first year, primary THA was favorable with regard to secondary hip procedures. It is reasonable to think that this difference may become more compelling beyond 2 years, as more patients who received hemiarthroplasty are likely to be converted to THA.
The suggestion that there may not be an early benefit of THA over hemiarthroplasty in the ambulatory adult with a displaced femoral neck fracture contrasts with current recommendations from the American Academy of Orthopaedic Surgeons. However, the 2-year follow-up of this trial represents only a “snapshot” of the continuum of outcomes from these two hip-fracture treatments. The findings may add to our understanding of what our patients can expect during the first 2 years following these procedures, but I would caution surgeons against making any drastic changes to their current practice in response to this data.
Paul E. Matuszewski, MD is the Director of Orthopaedic Trauma Research and Assistant Professor of Orthopaedic Traumatology at the University of Kentucky.
Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
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.
Fracture fixation with a plate and screws has been around for a century—and so has the problem of screw loosening. Part of the cause of screw loosening seems to be toggling caused by radial forces arising from plate micromotion. Several decades ago, locked screws were designed to prevent loosening and provide better fixation, but screws still loosen.
Two tests can predict screw loosening associated with bone microfracture and absorption: axial pullout stress and toggling radial stress. Recent studies have investigated two hypotheses: radial stress is a predominant cause of screw loosening, and bone resorption is triggered by high radial stress.
Finite Element Analyses
A finite elemental model was used to replicate fixation of a tibial fracture with a 3-mm gap using either a dynamic compression plate (DCP) or locking compression plate (LCP).1 The model included contact with bone, tension on screw insertion, and the placement of two inner screws and one outer screw on either side of the fracture for an 8-hole plate. Axial loading, torsional loading, and bending were applied. Forces exceeding 55 megapascal (MPa) were considered adequate to cause microfracture, whether by radial or axial force. (For reference, 55 MPa is just about 8,000 pounds per square inch.)
The principal finding was that more bone was damaged by radial than by axial stress in both types of plates. Both plate types had more bone damaged by radial stress at the central two screws than at the two end screws for all bending models.
A separate study evaluated clinical radiographs of fixation for humeral, radial, ulnar, femoral, and tibial shaft fractures. Researchers looked for screw migration or bone absorption of ≥1 mm around the screw. Both DCPs and LCPs were reviewed.
Researchers found that the outer screws loosened only after the inner screws loosened. There were 3 cases of bone loss with no loosening, 17 cases of bone loss with screw displacement, and no cases of screw loosening without bone loss. This strongly suggests that bone loss must occur for loosening to take place and that the earliest screw loosening occurs closer to the facture site.
Taken together, these results imply that the use of larger inner screws and/or the use of a different angle of fixation might reduce bone absorption that leads to loosening. In addition, radial stress testing might be more important than axial testing. Still, LCPs remain superior at resisting axial loading and bending moments, while DCPs remain superior at resisting torsional loading of unstable fractures.
- Feng X, Lin G, Fang CX, Lu WW, Chen B, Leung FKL. Bone resorption triggered by high radial stress: The mechanism of screw loosening in plate fixation of long bone fractures. J Orthop Res. 2019 Jul;37(7):1498-1507. doi: 10.1002/jor.24286. Epub 2019 Apr 8 PMID: 30908687