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More Evidence: Coordinated Care Reduces Risk of Second Fragility Fracture

Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.

Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.

The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.

These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”

JBJS 100: Femoral Fractures, Shoulder Dislocations

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Closed Intramedullary Nailing of Femoral Fractures
RA Winquist, ST Hansen Jr, DK Clawson: JBJS, 1984 January; 66 (4): 529
This paper, which carefully explains how IM nailing procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.

Nonoperative Treatment of Primary Anterior Shoulder Dislocation in Patients 40 Years of Age and Younger
L Hovelius et al: JBJS, 2008 May; 90 (5): 945
After 25 years of follow-up, half of >200 primary shoulder dislocations in Swedish patients aged 12 to 25 that had been treated nonoperatively had not recurred or had become stable over time. Based on these findings, the authors opine that “routine, immediate surgery for the treatment of all first-time dislocations in patients 25 years of age or younger will result in a rate of unnecessary operations of at least 30%.”

Young Kids and Lawn Mowers Don’t Mix

Amputation for OBuzzUntil I completed my pediatric orthopaedics rotation as a resident, I never thought much about pediatric lawn-mower injuries. I don’t recall how many such accidents we cared for during that time period, but I clearly remember one. It was grotesque and life-changing for the child–and definitely avoidable. That recollection was reinforced while I read the epidemiological study by Fletcher et al. in the October 17, 2018 edition of The Journal.

The authors analyzed 20 years of data from their institution in an effort to better understand these horrific injuries. They found two main demographic populations among the 157 patients who sustained mower-related injuries, which were lower-extremity injuries in 84% of all the patients. Those in the younger at-risk population (mean age of 4 years) were frequently injured by (or were passengers on) a riding lawn mower, usually operated by an older family member. This younger cohort had higher injury severity scores and higher amputation rates than the older pediatric population of mower-injured patients (mean age of 15 years). Most of those older patients were hurt while operating the lawn mower themselves.  Not surprisingly, the authors found that these patients, whatever their age, underwent an average of almost three operations and spent close to a week in the hospital.

While there are a lot of important epidemiological data points in this article, the most important take-home message is the role that education must play in the prevention of these injuries.  As the author state:

Education for the younger population should target the operators (parents, grandparents, older siblings) and emphasize the importance of keeping children out of the yard while lawn mowers are in use. Under no circumstance should a child of any age be the passenger on a lawn mower.

Despite ample literature on lawn-mower injuries, their incidence among pediatric patients has remained largely unchanged. I’m hopeful that this study will prompt more widespread implementation of patient education in this area. The American Academy of Orthopaedic Surgeons has information regarding lawn mower safety, and the Pediatric Orthopaedic Society of North America and the American Academy of Pediatrics are partnering on lawn-mower injury prevention. Accidents cannot be eradicated completely,  but the more we avail ourselves of resources such as these—and  share them with patients of all ages—the greater the likelihood of preventing these potentially devastating injuries.

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

Less Pain, More Gain with Just One Screw

Transiliac Screw for OBuzz

Image courtesy of AO Surgery Reference

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD in response to a recent study in the Journal of Orthopaedic Trauma.

Low-energy sacral fractures in the geriatric population typically heal over time without operative intervention. Nonoperative treatment usually involves analgesics and progressive rehabilitation. Unfortunately, given the frailty and low physiologic reserves of many in this patient population, these fractures can still take a significant toll. Fracture pain may last for weeks to months; deconditioning occurs secondary to poor mobilization; and many patients are discharged to skilled nursing facilities rather than returning directly home.

Given this associated morbidity, Walker et al.1 asked whether percutaneous transiliac-transsacral screw fixation could offer some benefit in the treatment of sacral fragility fractures. The authors present a retrospective review of 41 elderly patients who were admitted with sacral fragility fractures. All patients first received a trial of nonoperative management, which included analgesia and physical therapy-guided mobilization. If patients were unable to appropriately ambulate secondary to pain, they were offered surgery. Sixteen patients elected surgery, which consisted of transiliac-transsacral screw fixation of the posterior pelvic ring.

After surgery, the operative group reported greater reductions in pain than the nonoperative cohort, and they were more likely to be discharged directly home from the hospital (75% versus 20%). Furthermore, at the time of discharge, 100% of the surgical patients were able to ambulate with physical therapy, compared to only 72% of the nonoperative group. No surgical complications occurred, and the average total surgical time was only 34 minutes.

Sacral fragility fractures can result in significant pain and disability in an already frail population. While these fractures are typically managed conservatively, this study suggests that some patients may benefit from surgical intervention. Percutaneous transiliac-transsacral screw fixation is a relatively low-risk procedure (at least in the normomorphic sacrum). And if a single screw can reduce pain, improve function, and more quickly return geriatric patients to their baseline level of independence, then the risk-benefit calculus would favor surgery, unless specific contraindications are present.

While this study is not powerful enough to rewrite treatment protocols, it does give credence to considering surgical fixation for sacral fragility fractures in those who still struggle after a trial of conservative management, and it makes a strong argument for further investigation.

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.

Reference

  1. Walker, J. Brock, et al. “Percutaneous Transiliac–Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home.” Journal of orthopaedic trauma 32.9 (2018): 452-456.

New Isn’t Always Better

NIRS and IMP for OBuzzDiagnosing acute compartment syndrome (ACS) is challenging. The signs and symptoms of ACS are easy to conflate with those of the overall musculoskeletal injury; the treatment, fasciotomy, is not without risks; and the consequences of delaying or missing the diagnosis altogether can be catastrophic. It is for these reasons that the notion of a device that can continuously monitor a wounded extremity for ACS and alert surgeons when intervention should be considered is so appealing. Yet, as the study by Schmidt et al. and the METRC group in the October 3, 2018 JBJS suggests, the ideal and reality are not aligned.

In this prospective blinded study, the authors evaluated the ability of near-infrared spectroscopy (NIRS) sensors and intramuscular pressure (IMP) catheters to monitor the tissue oxygen-saturation and compartment pressures, respectively, of patients who sustained an injury that is associated with the development of compartment syndrome. They found that clinically useful NIRS data was available only about 9% of the time, whereas IMP information was available >85% of the time.  Certain injury characteristics (such as  fractures associated with hematomas) made obtaining data with the NIRS especially difficult.

While these results don’t bode well for NIRS as a reliable ACS monitoring tool, it should be noted that the users of the NIRS system in the study were mostly unaware of when the NIRS system was not collecting clinically useful data in real time. Obviously, you can’t correct a problem if you don’t know it exists, and it is possible the results of the study would have been different if NIRS users were able to troubleshoot the system when data were not being captured. Still, after reading this article, it seems difficult to justify using NIRS to monitor a patient for development of ACS.

New diagnostic tools and techniques are always being developed, and we should remember the results of this study when any “new-fangled” device enters the clinical landscape. A test’s most important feature is its ability to reliably provide clinically useful data to aid in decision-making.  If it cannot do so, it is simply providing distracting ”noise” from which misinterpretations can be made.

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

Fracture Risk Rises after Gastric Bypass Surgery

Gastric Bypass for OBuzzThis 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. 

Nearly 200,000 Americans have bariatric surgery each year, so it’s important to understand the long-term musculoskeletal consequences of those procedures. Gastric bypass constitutes the most common bariatric surgery and is believed to lead to bone loss. However, fracture risk in gastric-bypass patients has been insufficiently studied. Given that diabetes is an independent risk factor for fractures, any gastric bypass–fracture association should be studied in patients with and without diabetes.

That’s what Swedish researchers did in a retrospective cohort study1 of 38,971 obese patients who underwent gastric bypass—7,758 of whom had diabetes and 31,213 of whom did not. The patients in each of the two groups were propensity-score matched with controls (1 to 1). The researchers evaluated the overall risk of fracture and fall injury, along with fracture risk according to amount of weight loss and degree of calcium and vitamin D supplementation during the first year after surgery.

After a median follow-up of 3.1 years, gastric bypass was associated with an increased risk of any fracture, both in patients with diabetes (HR, 1.26) and without diabetes (HR, 1.32). Fracture risk appeared to increase with time. The risk of fall injury without fracture also increased after gastric bypass. (The increased risk of fall injury may explain some of the increased fracture risk.) Surprisingly, neither higher amounts of weight loss nor poor calcium and vitamin D supplementation during the first year after surgery were associated with increased fracture risk.

The metabolic consequences of surgically induced weight loss are significant for the obese population. Those consequences probably reach beyond bone to affect many aspects of musculoskeletal and possibly neurological homeostasis.

Reference

  1. Axelsson KF, Werling M, Eliasson B, Szabo E, Näslund I, Wedel H, Lundh D, Lorentzon M. Fracture Risk After Gastric Bypass Surgery: A Retrospective Cohort Study. J Bone Miner Res. 2018 Jul 16. doi: 10.1002/jbmr.3553. [Epub ahead of print] PMID: 30011091

BOG Fracture-Risk Score Combines DNA Info with Physiological Factors

Fracture Risk Image for OBuzzThis 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. 

During childhood and adulthood, we often put ourselves at risk for future fractures based on our activity, diet, and social habits. Many factors affect the risk of both stress fractures in younger people and fragility fractures later in life. Everyone—but especially athletes and active-duty military personnel—could benefit from an early heads-up regarding their genetic and phenotypic predisposition to stress fractures. Later in life, the FRAX index is a very useful multifactor risk score, but it is usually calculated only after a sentinel event, such as a fragility fracture.

Ultrasound is a readily available and inexpensive way to obtain an estimated heel bone mineral density (eBMD). Many common genetic variants contribute to the genetic basis for the eBMD phenotype. These variants are most commonly characterized by single nucleotide polymorphisms (SNPs, pronounced “snips”). Stanford researcher Stuart Kim developed the BMD Osteoporosis Genetic (BOG) risk score by combining 22,886 SNPs with data on height, weight, sex, and age.1 The correlation between actual eBMD and the BOG algorithm was 0.496, which was higher than the correlations achieved using the 22,886 genetic predictors or the four covariates alone.

Individuals with low BOG scores had a 17.4-fold increased risk for osteoporosis compared to those with the median BOG score. Low BOG scores were also associated with a 1.9-fold higher risk for bone fractures compared to median BOG values. However, the algorithm’s ability to discriminate cases from controls in the overall population was modest. The receiver operator area under the curve for predicting osteoporosis or fracture by the BOG algorithm was 0.78 and 0.57, respectively.

Although the effect of an individual SNP may be inconsequential, the cumulative effect from many SNPs can be large. The author stated that “an algorithm such as the BOG risk score might be useful to screen the general population…to identify individuals that warrant closer examination, such as BMD measurement via DXA [dual-energy X-ray absorptiometry].”

Reference

  1. Kim SK. Identification of 613 new loci associated with heel bone mineral density and a polygenic risk score for bone mineral density, osteoporosis and fracture. PLoS One. 2018 Jul 26;13(7):e0200785. doi: 10.1371/journal.pone.0200785. eCollection 2018. PMID: 30048462

JBJS 100: Talar Neck Fractures, Knee Cartilage Repair

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Fractures of the Neck of the Talus
L G Hawkins: JBJS, 1970 July; 52 (5): 991
This article, richly illustrated with radiographs, reports on >1-year results from 43 patients treated after sustaining a vertical fracture of the neck of the talus. Hawkins introduced a 3-group classification system based on the initial radiographic appearance of the fracture, and he provided an in-depth discussion of the complication of avascular necrosis.

Autologous Chondrocyte Implantation and Osteochondral Cylinder Transplantation in Cartilage Repair of the Knee Joint
U Horas, D Pelinkovic, G Herr, T Aigner, R Schnettler: JBJS, 2003 February; 85 (2): 185
In the 15 years since this paper appeared in JBJS, nearly 800 articles have been published that have “autologous chondrocyte implantation” (ACI) in their title. This study—replete with histologic, biopsy-specimen, and electron microscopy images—compared 2-year results among 40 patients who had received either ACI or autologous osteochondral transplants for knee cartilage defects. Both treatments decreased symptoms, but the authors concluded that “the improvement provided by the [ACI] lagged behind that provided by the osteochondral cylinder transplantation.” For more current information on these cartilage-repair techniques, see the JBJS Clinical Summary on Knee Cartilage Injuries.

JBJS 100: Harris Hip Score, Clavicle Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures—Treatment by Mold Arthroplasty: An End-Result Study Using a New Method of Result Evaluation
W H Harris: JBJS, 1969 June; 51 (4): 737
The most lasting legacy from this classic 1969 article from William Harris is the author’s proposed hip score. A “single, reliable figure” designed to be equally applicable to different hip problems and different treatments, the Harris Hip Score is still used worldwide today in routine evaluations before and after hip arthroplasty. Not surprisingly, this article remains the most frequently cited paper in the hip arthroplasty literature.

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures
Canadian Orthopaedic Trauma Society: JBJS, 2007 January; 89 (1): 1
Amid the ongoing debate about whether to operate on which type of clavicle fractures, this multicenter, randomized clinical trial stands out for its rigorous design and focus on patient-oriented outcomes. Local irritation and unsightly prominence from hardware notwithstanding, these findings support primary plate fixation of completely displaced midshaft clavicle fractures in active adult patients.

Opioid-Tapering Plan May Help Prevent Prolonged Use after Trauma/Surgery

Hydrocodone Has Dark Side as Recreational DrugAddressing the opioid epidemic requires a concerted effort from all sectors of society, but the role of surgeons (orthopaedic and otherwise) cannot be ignored because they determine how best to manage postoperative pain for millions of patients. OrthoBuzz recently commented on two opioid-related studies from the July 18, 2018 issue of JBJS. In the August 1, 2018 edition of The Journal, Mohamadi et al. explain findings from a meta-analysis of 37 studies involving nearly 2 million patients that pinpoint several patient-related risk factors associated with opioid use beyond 2 months following surgery or trauma.

Using careful meta-analysis methods, the authors determined that about 4% of patients continued to use prescription opioids beyond 2 months after surgery or trauma. They also identified the following risk factors as being “among the most important predictors of prolonged opioid use” in these patients:

  • Prior use of opioids or benzodiazepines
  • Depression
  • Long-duration hospital stay
  • History of back pain

Mohamadi et al. also calculated a “number needed to harm” (NNH) from their data. NNH indicates the number of patients with a certain risk factor that is necessary to result in 1 person with prolonged opioid use beyond that of a patient population without that risk factor. They found that for every 3 patients with a history of opioid use, every 23 patients with a history of back pain, every 40 with depression, or every 62 with a history of benzodiazepine use, 1 patient will continue to use prescribed opioids for an extended time period.

Because this meta-analysis was derived from observational studies, the authors caution that “causal inferences could not be drawn for the proposed risk factors.” But they do offer a practical piece of advice gleaned from prior research: Provide patients with an opioid-tapering plan at the time of discharge to significantly reduce the likelihood of prolonged opioid use.