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JBJS Announces 2019 EST Award Winners

JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) article, and the other for the best Key Procedures (KP) video published during each calendar year.

We are pleased to announce the winners for 2019:

Both articles are freely available online until the end of August 2020.

Submissions for the 2020 EST Awards are currently being accepted.

Preop Nerve Blocks for Hip Fractures – Sooner Is Better

The benefits of peripheral nerve blocks for pain control and decreased use of opioids has been well-established for several orthopaedic procedures. In the May 20, 2020 issue of The Journal, a prospective cohort study by Garlich et al. shows that administering such a block earlier rather than later significantly benefits elderly patients awaiting surgery for a hip fracture.

The authors looked at whether the time to block (TTB) with a fascia iliaca nerve block (FIB) in a cohort of 107 patients who sustained a hip fracture affected preoperative opioid consumption and postoperative pain scores. They also examined the relationship between TTB and length of stay and adverse events related to opioids. All FIBs were performed between the time of emergency department arrival and ≥4 hours prior to surgery. Those parameters allowed time for the block to work and also time for the patients in this cohort to request pain medication.

Preoperatively, 72% of all opioid consumption took place prior to block placement. Patients experiencing a faster TTB consumed fewer opioids preoperatively and also on postoperative days 1 and 2, although the day-2 differences were not statistically significant. More specifically, Garlich et al. found a 63.7% reduction in the median preoperative opioid consumption in those with a TTB <8.5 hours from the time of arrival, relative to those whose TTB was ≥8.5 hours.

In addition, patients with a TTB <8.5 hours had significantly lower pain scores on postoperative day 1, and their hospital stays were significantly shorter than those who received blocks ≥8.5 hours after arrival (4.0 days versus 5.5 days). There were no differences in opioid-related adverse events between the TTB groups, although commentator Dr. Patrick Schottel notes that the study was underpowered to definitively discern those between-cohort differences.

Overall, this important study shows that early preoperative FIB reduces perioperative opioid consumption in geriatric patients with hip fractures, in addition to decreasing their pain scores and length of hospital stay. Further investigation is needed to determine the optimal timing for administering preoperative blocks in this vulnerable population.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

High-Level Clinical Research in Developing Countries? Yes!

Generally speaking, orthopaedic surgeons in low-resourced environments deliver the best care for their patients with skill, creativity, and passion. These surgeons are accustomed to scrambling for implants and other tools and to working around limited access to operating theaters and anesthesia services. Their everyday struggles usually leave little energy or time to even think about clinical research.

However, in the May 20, 2020 issue of The Journal, Haonga and colleagues prove that, with a “little help from their friends,” it is possible to conduct Level I research while treating patients in a resource-limited setting. They enrolled and followed 221 patients with open tibial fractures (mostly males in their 30s injured in a road-traffic collision) and randomized them to treatment with either uniplanar external fixation or intramedullary (IM) nailing. The nails were supplied by SIGN Fracture Care International, a not-for-profit humanitarian organization that provides specially designed IM nails that can be used without image intensification to hospitals in developing countries around the world. (See related OrthoBuzz post.)

The research was done in Dar es Salaam, Tanzania, in collaboration with trauma surgeons and epidemiologists from the University of California San Francisco, which has a long-standing relationship with Tanzania’s Muhimbili National Hospital. At the 1-year follow-up, there were no significant between-group differences in primary-outcome events—death or reoperation due to deep infection, nonunion, or malalignment. IM nailing was associated with a lower risk of coronal or sagittal malalignment, and quality-of-life (QoL) scores favored IM nailing at 6 weeks, but QoL differences dissipated by 1 year.

Just as important as the clinical findings, these investigators proved that it is possible to do high-level research in centers with high patient volume and limited resources. Future patients will benefit because the clinicians now have better information to share regarding expectations for functional recovery and risk of infection. Physicians and other healthcare professionals benefit because data like this help improve their analytical skills and become more discerning appraisers of the published literature. With strong internal physician leadership and a little outside support, Haonga et al. have convinced us that prospective—and even randomized—research is possible in these special places.

Finally, SIGN deserves our support as a true champion of orthopaedic surgeons working in under-resourced environments. In addition to providing education and implants, SIGN surgeons are required to report their cases through the SIGN Surgical Database—which encourages the research mindset and helps SIGN surgeons improve tools and techniques for better patient outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

COVID-19 Patients: Better Breathing After Fracture Surgery

COVID-19 infections spread rapidly in northern Italy from February to April of 2020. During that time, the orthopaedic unit at Humanitas Gavazzeni Hospital in Bergamo focused on elderly patients with both a femoral neck fracture and COVID-19. In a fast-tracked JBJS study, Catellani et al. report on what happened to 16 COVID-19-positive patients who were admitted to the hospital’s emergency department with a proximal femoral fracture:

  • 3 patients died from severe respiratory insufficiency and multiple-organ failure before surgery could be considered or performed.
  • 10 patients underwent fracture surgery on the day after admission; 3 had surgery on the third day after admission to allow washout of direct thrombin inhibitors.
  • Oxygen saturation improved in all patients who underwent surgery except 1
  • Hemodynamic and respiratory stability was achieved in 9 patients at an average of 7 days postsurgery.
  • 4 patients who underwent surgery died of respiratory failure—1 on the first day after surgery, 2 on the third day after surgery, and 1 on the seventh day after surgery.

In general, the advantages of early treatment of proximal femoral fractures in the elderly include early mobilization and better pain control. On the other hand, orthopaedists consider severe respiratory insufficiency to be a contraindication to anesthesia and surgery. The anesthesiology team working with Catellani et al. recommended early surgery in these patients if their oxygen saturation was >90% and their body temperature was <38°C. Spinal anesthesia was used for all patients to avoid sedation and was combined with a peripheral femoral nerve block to achieve better pain management.

The authors concluded that most of these COVID19-positive patients who presented in less critical condition and underwent carefully planned and executed surgery for proximal femoral fractures experienced a notable stabilization of their respiratory parameters.

Weight-Bearing CT: An Incremental Step in Addressing Posttraumatic Ankle Arthritis

Orthopaedic surgeons recognize that an intra-articular fracture of the distal tibia (pilon fracture) is the worst actor when it comes to the sequela of posttraumatic ankle osteoarthritis. Despite decades of focusing on surgical techniques that yield the best-looking postoperative radiographs, we have come to realize that, to reduce the risk of subsequent arthritis, limiting the extent of the surgical approach may be as important as achieving the “perfect” articular reduction. Slowly we have come to understand that articular cartilage damage from the injury (and in some instances exacerbated by overaggressive surgical dissection) is as big a factor as the bone injury in terms of postoperative joint-space narrowing and its associated ankle stiffness and pain.

Thankfully, the orthopaedic trauma community is making strides toward new biologic, mechanical, and rehabilitative interventions that have the potential to limit this articular narrowing. But to meaningfully evaluate the effectiveness of these strategies, we need not only validated patient-oriented functional outcome measures, but also more reliable and reproducible ways to assess the joint-space narrowing.

In the May 6, 2020 issue of The Journal, Willey et al. report on a standardized technique using weight-bearing computed tomography (WBCT), which yields a 3D assessment of the postoperative joint space with the ankle in a loaded, functional position (see Figure above). When this technique was applied to 20 patients (mean age of 44 years) with a partial or complete articular pilon fracture 6 months after surgical treatment, the authors found significantly less tibiotalar joint space in the injured ankle compared with the uninjured ankle. Interrater correlation and test-retest data indicated that this method has good measurement reliability and reproducibility.

Any safe, reliable, and reproducible measure of early joint-space narrowing after pilon fracture surgery is an important incremental step in designing clinical trials that will assess new interventions designed to preserve postoperative joint space—and hopefully reduce the incidence of posttraumatic ankle arthritis. Willey et al. have demonstrated the usefulness of WBCT as such a modality.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Romosozumab for Hip Fractures: All That Glitters Is Not Gold

We have all come to realize that promising results from lab studies or preclinical trials in animal models do not always translate into meaningful clinical benefits in humans. Yet it is vitally important to perform those human trials to ascertain that knowledge. This is demonstrated by Schemitsch et al. in the April 15, 2020 edition of The Journal. The authors performed a Level I, double-blinded, randomized controlled trial comparing varying doses of romosozumab to placebo in the treatment of older patients with a hip fracture.

Romosozumab is a sclerostin-inhibiting antibody that helps increase bone formation while decreasing resorption. It is indicated to treat osteoporosis in postmenopausal women, in whom the drug has been shown to increase bone mineral density and reduce the risk of fragility fractures. In multiple preclinical studies, romosozumab has increased bone mass and bone strength in rodent osteotomy models, suggesting it might possibly promote fracture healing in people.

In the current study, Schemitsch et al. randomized patients between 55 and 95 years old who had a low-energy hip fracture amenable to internal fixation to receive 3 postsurgical subcutaneous injections of romosozumab at doses of either 70 mg (60 patients), 140 mg (93 patients), or 210 mg (90 patients), or to receive 3 placebo injections (89 patients). The primary end point was the validated “timed Up and Go” (TUG) score. The authors also measured the Radiographic Union Scale for Hip (RUSH) score, and hip pain on a visual analog scale (VAS).

The authors enrolled 325 patients, with 263 (79.2%) reaching the 24-week follow up and 229 (69.0%) reaching the 52-week follow up. They found no statistically significant between-group differences in the TUG, with all patients improving and plateauing at week 20. Similarly, there were no differences between any of the treatment arms in time to radiographic healing, RUSH scores, or VAS. The safety profile of the medication was similar between the 3 romosozumab doses and the placebo.

Romosozumab may increase bone mineral density and reduce the risk of fragility fracture in patients with osteoporosis, but when it comes to helping heal hip fractures, it did not prove to be more advantageous than placebo. This shows, yet again, that what may glitter in animal studies may not necessarily shine like gold in clinical trials with people.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Treating Transitional Ankle Fractures: Best Evidence Yet

Transitional fractures of the ankle in adolescents are related to torsional injuries that occur around the time that the distal tibial physis begins to close. In recent years, treatment has moved toward screw fixation when the intra-articular fracture gap in Salter type III (Tillaux) and type IV (triplane) fractures is  between 1 mm and 2 mm. The rationale for operative treatment has been that intra-articular fracture gaps should be completely reduced, particularly in younger patients, to limit the long-term risk of post-traumatic osteoarthroses. However, evidence supporting the wisdom of surgical intervention has been thin at best. (See Clinical Summary on Triplane Ankle Fractures.)

In the April 15, 2020 issue of The Journal, Lurie et al. report on a retrospective analysis of 34 patients with a triplane fracture and 23 patients with a Tillaux fracture, all of which had 2 mm to 5 mm of articular displacement. Among those 57 patients, 34 were treated with surgery and 23 with closed reduction and casting.

Based on regression analysis, nonoperative treatment, a larger intra-articular gap after closed reduction, and the presence of a grade-III complication were associated with worse functional outcomes at a mean follow-up of 4.5 years. Patients who were treated nonoperatively and had a gap ≤2.5 mm had significantly better functional scores than similar patients with a gap >2.5 mm. From this data, the authors conclude that “surgical management of these injuries likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm.”

This study has the usual issues of treatment and detection bias inherent in retrospective reviews, and the measurement of fracture gaps, even with the CT scans these authors used, is not always reliable at this level of precision. Nevertheless, this data from Lurie et al. is the best we have to date to indicate that the so-called “2-mm rule” of nonoperative management of transitional ankle-fracture gaps  ≤2 mm probably makes sense in most clinical situations.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

More Pre-op Bone Health Evaluations Needed

“We believe that bone health screening should be considered in all orthopaedic surgical candidates who are ≥50 years of age.” So proclaim Kadri et al., based on results of their study of 124 patients who were referred by orthopaedic surgeons for preoperative bone health optimization. The study appeared in the April 1, 2020 issue of The Journal of Bone & Joint Surgery.

The importance of identifying poor bone health before reconstructive orthopaedic surgery is well known but poorly implemented. The bone health evaluation in this cohort consisted of a physical examination, structured history-taking focused on prior fracture, and collection of Fracture Risk Assessment Tool (FRAX) data. Most (122 patients) also underwent dual X-ray absorptiometry (DXA), and more than two-thirds were evaluated with a trabecular bone score. Incidental CT scans were available for and evaluated in 43 patients. Based on these data, Kadri et al. found the following:

  • >90% of the cohort met National Osteoporosis Foundation criteria for osteoporosis treatment.
  • A high FRAX risk (major osteoporotic fracture ≥20% or hip ≥3%) was present in 82% of the patients.
  • Osteoporosis, as defined by T scores of ≤─2.5 points, was present in 45% of the women and 20% of the men.
  • Trabecular bone scores identified 34% of patients as having degraded bone microarchitecture.

As a result of these findings, 75% of the cohort were prescribed treatment for osteoporosis; 45% were prescribed anabolic agents and 30% were prescribed antiresorptive therapy.

For patients with clinical risk factors for osteoporosis and high FRAX risk, Kadri et al. recommend bone health optimization strategies for a minimum of 3 months prior to any planned orthopaedic surgery. “It has been our experience that patients are generally satisfied and are grateful to undergo bone health optimization despite a delay in the surgical procedure,” they write.

Although postsurgical outcomes among these patients were not analyzed, the authors intuitively point out that bone health optimization probably reduces the likelihood of postoperative complications and revisions and therefore would lead to improved outcomes and lower costs. Preoperative bone health optimization could also help surgeons select the most effective surgical technique and/or implant, they say.

Amid COVID-19, What Does “Elective” Mean?

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.

Prepping for Surgery on Patients with COVID-19

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.