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
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.
We orthopaedists obtain radiographs for many reasons—to diagnose an unknown problem, to determine the progress of healing, and occasionally because we follow X-ray “dogma” acquired over time. That last reason prompted van Gerven et al. to undertake a multicenter, prospective, randomized controlled trial, the findings of which appear in the August 7, 2019 issue of The Journal.
The authors set out to evaluate the clinical utility of radiographs taken after a distal radial fracture in >300 patients. Some of those fractures were treated nonoperatively, while others underwent operative fixation. Surgeons of the patients randomized to the “usual-care” pathway were instructed to obtain radiographs at 1, 2, 6, and 12 weeks following the injury/surgery. Surgeons of patients in the “reduced-imaging” arm did not obtain radiographs beyond 2 weeks after the injury/surgery unless there was a specific clinical reason for doing so.
The authors found no significant differences between groups in any of the 6 patient-reported outcomes measured in the study, including the DASH score. Furthermore, the complication rates were almost identical between the usual-care (11.4%) and reduced-imaging (11.3%) groups. Not surprisingly, patients in the reduced-imaging group had fewer radiographs obtained (median 3 vs 4) and were exposed to a lower overall dose of ionizing radiation than those in the usual-care group.
Probably because the study was conducted in the Netherlands, it did not address the widespread practice of “defensive medicine” in the US—the unnecessary overuse of medical tests and procedures to reduce the risk of a malpractice claim. While that may limit the external validity of these findings among orthopaedists in the United States, this relatively simple yet well-designed study should remind us that it is important to have a definite clinical purpose when ordering a test of any type. A picture may be worth a thousand words, but sometimes it takes only 2 pictures to tell the full story of a healing distal radial fracture.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Orthopaedic surgeons work with radiation in some capacity almost every day. We would struggle to provide quality patient care if it were not for the many benefits that radiographic images provide us. But the more we are exposed to something, the less we tend to think about it. For example, how often do we discuss the risks of radiation exposure with our patients—especially those who are exposed to a large amount of it after an acute traumatic injury?
The article by Howard et al. in the August 7, 2019 issue of JBJS strongly suggests that polytrauma patients need to better understand the risks associated with radiation exposure as they progress through treatment of their injuries. The authors evaluated the cumulative 12-month postinjury radiation exposure received by almost 2,400 trauma patients who had an Injury Severity Score of 16+ upon admission. Those patients received a median radiation dose (not counting fluoroscopy) of 18.46 mSv, and their mean radiation exposure was 30.45 mSv. These median-versus-mean data indicate that a small subset of patients received substantially more radiation than others, and in fact, 4.8% of the cohort was exposed to ≥100 mSv of radiation. To put these amounts in context, the average human in the UK (where this study was performed) is exposed to about 2 mSv of background radiation per year, and there is good evidence suggesting that carcinogenesis risk increases with acute radiation doses exceeding 50 mSv.
Based on mathematical models (actual occurrences of cancer were not tracked), the authors conclude that for these patients, the median risk of fatal carcinogenesis as a result of medical radiation following injury was 3.4%. In other terms, 85 of these patients would be expected to develop cancer as a result of medical imaging—which struck me as a startling estimate.
So what are we to do? In a Commentary accompanying this study, David A. Rubin, MD, FACR offers some practical suggestions for reducing unnecessary radiation exposure. I personally feel that because the radiation associated with CT scans and radiographs can be, quite literally, life-saving for patients who have sustained traumatic injuries, increasing the chance that patients develop cancer later in life in order to save their life now is a good risk-benefit proposition. But the findings from this study should make us think twice about which imaging tests we order, and they should encourage us to help patients better understand the risks involved.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 25 noteworthy studies summarized in the July 3, 2019 “What’s New in Orthopaedic Trauma” article.
Proximal Humeral Fractures in the Elderly
–A recent meta-analysis1 analyzing data from >1,700 patients older than 65 who experienced a proximal humeral fracture found no difference in Constant-Murley scores at 1 year between those treated operatively (most with ORIF using a locking plate) and those treated nonoperatively. There was also no between-group difference with respect to reoperation rates among a subgroup of patients from the 7 randomized trials examined in the meta-analysis.
–A study using MRI to evaluate soft-tissue injuries in 17 cases of “simple elbow dislocation”2 found that the most common soft-tissue injury was a complete tear of the anterior capsule (71% of cases), followed by complete medial collateral ligament (MCL) tears (59%) and lateral collateral ligament tears (53%). These findings challenge previous theories positing that elbow instability starts laterally, with the MCL being the last structure to be injured.
Pertrochanteric Hip Fractures
–A trial randomized 220 patients with a pertrochanteric fracture to receive either a short or long cephalomedullary nail.3 There were no significant differences between the 2 groups at 3 months postsurgery in terms of Harris hip and SF-36 scores, but patients treated with the short nail had significantly shorter operative times, less blood loss, and shorter hospital stays. The incidence of peri-implant fractures between the 2 devices was similar.
Ankle Syndesmosis Injuries
–A randomized trial involving 97 patients with syndesmosis injuries compared functional and radiographic outcomes between those treated with a single syndesmotic screw and those treated with suture-button fixation. At 6 months, 1 year, and 2 years after surgery, patients in the suture-button group had better AOFAS scores than those in the screw group. CT scans at 2 years revealed a significantly higher tibiofibular distance among the screw group, an increase in malreduction that was noted only after screw removal. That finding could argue against early routine syndesmotic screw removal.
–A randomized trial among 470 patients4 facing elective removal of hardware used to treat a below-the-knee fracture compared the effect of intravenous cefazolin versus saline solution in preventing surgical site infections (SSIs). The SSI rate was surprisingly high in both groups (13.2% in the cefazolin group and 14.9% in the saline-solution group), with no statistically significant between-group differences. The authors recommend caution in interpreting these results, noting that there may have been SSI-diagnosis errors and that local factors not applicable to other settings or regions may have contributed to the high SSI rates.
- Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH,Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg.2018 Aug;27(8):1526-34. Epub 2018 May 4.
- Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg.2019 Feb;28(2):341-8. Epub 2018 Nov 8.
- Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
- Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED,Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI,Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. 2017 Dec 26;318(24):2438-45.
Among the elderly, low-energy hip fractures are common injuries that almost all orthopaedic surgeons encounter. While operative management is typically the standard of care, there are some patients for whom nonoperative treatment is most aligned with their goals of care, usually because of chronic disease, fragility, and/or high risk of perioperative mortality.
When counseling elderly patients and family members about the risks and benefits of surgical management for a hip fracture, we have abundant data. We can estimate the length of rehabilitation, discuss the likelihood of regaining independence with ambulation, and quote the 30-day, 1-year, and 5-year mortality statistics. But what about the risks and benefits of nonoperative care? How long do these patients live? How many are alive 1 year after the fracture?
Chlebeck and colleagues attempt to answer those questions with a retrospective cohort study of 77 hip fracture patients who were treated nonoperatively and a matched cohort of 154 operatively treated hip fracture patients. Nonoperative management was chosen only after a palliative-care consult was obtained and after a thorough multidisciplinary discussion of treatment goals with the patient and family. Patients who elected nonoperative care were treated with early limited weight bearing and a focus on maximizing comfort. Researchers established a comparative operative cohort through 2:1 matched pairing, controlling for age, sex, fracture type, Charlson Comorbidity Index, preinjury living situation, preinjury ambulatory status, and presence of dementia and cardiac arrhythmia.
As one might expect, there was significantly lower mortality in the operative group. The in-hospital, 30-day, and 1-year mortality for nonoperatively treated patients was 28.6%, 63.6%, and 84.4% respectively. The mortality rates seen in the operative cohort were 3.9%, 11.0%, and 36.4% respectively. A Kaplan-Meier survival analysis revealed the median life expectancy in the nonoperative cohort to be 14 days, versus 839 days in the operative group (p <0.0001). Interestingly, the researchers found no difference in hospital length of stay between the two groups (5.4 vs. 7.7 days; p=0.10).
These results provide useful references for orthopedic surgeons to use when counseling hip fracture patients and their families. Surgical intervention remains the standard of care in most instances, and this study suggests that operative care offers a significant mortality benefit over nonoperative care even in relatively unhealthy patients, like those selected for the matched operative cohort.
This study also gives us data to help guide the expectations of patients who decide surgery is not in line with their wishes. Half of the patients who elected nonoperative care in this study died within 14 days of admission, and only 15.6% were still alive at 1 year. Additionally, choosing nonoperative care does not lengthen hospitalization, suggesting that these patients can be quickly transferred to a more comfortable setting.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
See what JBJS Deputy Editor for Social Media Chad Krueger, MD thinks about the just-published Level-I trial comparing nonoperative treatment to volar locking plate fixation among 140 elderly patients with dorsally displaced distal radial fractures.