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JBJS 100: THA Registries, Bone-Repair Growth Factors

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 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, both from 2002:

The Swedish Total Hip Replacement Register
H Malchau, P Herberts, T Eisler, G Garellick, P Soderman: JBJS, 2002 November; 84 (Suppl 2): S2
In this 19-page analysis of data from the Swedish Total Hip Replacement Register, which was initiated in 1979, Malchau et al. pinpoint the striking clinical and socioeconomic effects of the Register’s first 20 years. The information captured by joint registries, especially in regions that provide universal health care coverage and thus maintain robust databases, has helped orthopaedic surgeons refine indications, surgical techniques, and implant choices.

The Role of Growth Factors in the Repair of Bone: Biology and Clinical Applications
J R Lieberman, A Daluiski, T A Einhorn: JBJS, 2002 June; 84 (6): 1032
Countless studies related to tissue engineering and the musculoskeletal system have been published in the 16 years since this Current Concepts Review  appeared in JBJS. Yet this article remains an essential primer for understanding how growth factors affect cells and tissues—and the possible applications for using growth factors to accelerate fracture healing, treat nonunions, and enhance spinal fusion.

Sarcopenia: An Independent Predictor of Mortality in Geriatric Acetabular Fractures

PLVIOrthoBuzz 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.

Fractures in the elderly are a growing problem in developed countries and generally carry a significant morbidity and mortality burden. When considering treatment strategies and making prognoses in this patient population, our ability to stratify patient frailty may be just as or more important than classifying the fracture. In a recent study in the Journal of Orthopaedic Trauma, Mitchell et al. evaluate the role of sarcopenia, an age-related loss of muscle mass, in predicting 1-year mortality among elderly patients with acetabular fractures.1

The authors performed a retrospective review of nearly 150 patients >60 years of age who sustained an acetabular fracture between 2003 and 2014. The authors used the lowest quartile of the psoas:lumbar vertebral index (PLVI) in the cohort as a surrogate for sarcopenia. The PLVI is calculated by measuring the cross-sectional area of the psoas muscle bellies at the L4 level and dividing that number by the cross-sectional area of the L4 vertebral body measured at the superior endplate (see image). Lower PLVIs represent greater loss of muscle mass.

After controlling for confounding variables, the authors found that sarcopenia was an independent risk factor for 1-year mortality. Specifically, patients with sarcopenia had a 32.4% 1-year mortality rate compared to a rate of 11.0% in patients without sarcopenia. Age and injury severity score (ISS) were also predictive of 1-year mortality, and patients with all 3 factors (age >75 years, ISS >14, and sarcopenia) had a mortality rate of 90%.

This article highlights the importance of risk-stratifying patients in ways that account for more than their presenting injuries. In the elderly population, chronologic age is only one of many indicators of frailty. Sarcopenia may be another marker that we can use to better understand the general well-being of our patients. As Mitchell et al. mention, more research must be done to precisely define a PLVI cutoff for sarcopenia to make this index a clinically useful tool. Ultimately, doing so will allow us to offer elderly patients and their families more thoughtful and evidence-based counseling regarding treatment and prognosis.

Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.

Reference

  1. Mitchell, Phillip M., et al., Sarcopenia is Predictive of 1-year Mortality After Acetabular Fractures in Elderly Patients.” Journal of Orthopaedic Trauma, June 2018; 32 (6) : 278-282.

JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing

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 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:

Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.

A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.

ADHD and a Drug that Treats It Raise Risk of Some Fractures

Stress Fx for OBuzz Few physicians or patients associate attention deficit hyperactivity disorder (ADHD) with an increased risk of traumatic or stress-related fractures. However, in the June 6, 2018 issue of JBJS, a study by Ben-Ami et al. corroborates previous research suggesting that such associations exist. The authors evaluated 100,000 Israeli Defense Forces recruits and found that subjects diagnosed with ADHD were significantly more likely to sustain a traumatic fracture than recruits having no ADHD diagnosis. Furthermore, they found that recruits with ADHD who were taking the stimulant methylphenidate to treat their symptoms had a significantly increased risk of sustaining a stress fracture compared to both recruits without ADHD and recruits who had ADHD but did not take the medication.

The association between methylphenidate exposure and increased risk of stress fracture makes sense, based on animal studies showing that the drug leads to increased bone resorption. However, until now I was unaware that patients with ADHD are at an increased risk of traumatic fracture as well. The authors postulate that such an association is secondary to the fact that ADHD often manifests with compulsive or inattentive behavior that may predispose these patients to injuring themselves. That theory is further supported by this study’s finding that the risk of traumatic fracture fell when those with ADHD took stimulant medications to control their symptoms.

When one considers that upwards of 5% of school-aged children and another 4% of  adults in the US are prescribed stimulant medication (not to mention the estimated 5% to 35% of US college students who abuse stimulants without prescription), these findings take on great importance.  Because of the large number of children and adults who rely on methylphenidate to control ADHD symptoms, it is important for both primary care physicians and orthopaedic surgeons to understand the association between this medication and stress fractures.

Although limited by the vulnerabilities typically found in observational, retrospective designs, this study’s findings add to a growing body of evidence highlighting the potential fracture risks associated with stimulant medication. We probably encounter patients taking such medications on a regular basis in our practices. These data should prompt us to ask more questions of patients who have sustained stress fractures to determine whether stimulant medication usage may be an underlying cause.

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

Orthopaedic Surgeons Hate Fixation Failures

IM Nail for Hip Fx for OBuzzFew things are more disheartening to an orthopaedic surgeon than taking a patient back into the operating suite to treat a failure of fixation. In part, that’s because we realize that the chances of obtaining stable fixation, especially in elderly patients with poor bone density, are diminished with the second attempt. We are additionally cognizant of the risks (again, most significant in the elderly) to cardiopulmonary function with a second procedure shortly after the initial one.

These concerns have led us historically to instruct patients to limit weight bearing for 4 to 6 weeks after hip-fracture surgery. On the other hand, we have seen evidence in cohort studies to suggest that instructing elderly patients with proximal femur fractures to bear weight “as tolerated” after surgery is safe and does not increase the risk of fixation failure.

In the June 6, 2018 issue of The Journal, Kammerlander et al. demonstrate that 16 cognitively unimpaired elderly patients with a proximal femur fracture were unable to limit postoperative weight bearing to ≤20 kg on their surgically treated limb—despite 5 training sessions with a physiotherapist focused on how to do so. In fact, during gait analysis, 69% of these elderly patients exceeded the specified load by more than twofold, as measured with insole force sensors. This inability to restrict weight bearing is probably related to balance and lower-extremity strength issues in older patients, but it may be challenging for people of any age to estimate and regulate how much weight they are placing on an injured lower limb.

With this and other recent evidence, we should instruct most elderly patients with these injuries to bear weight as comfort allows and prescribe correspondingly active physical therapy. As surgeons, we should focus our efforts on the quality and precision of fracture reduction and placement of surgical implants. This will lead to higher patient, family, and physical-therapist satisfaction and pave the way for a more active postoperative rehabilitation period and better longer-term outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Predicting Failure of Femoral Neck Fixation

Femoral Neck Fracture for OBuzzOrthoBuzz 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.

With many problems in orthopaedics, the best management options are still being debated. The treatment of femoral neck fractures is one such problem. Surgeons have several available options: cancellous screws (CS), a sliding hip screw (SHS), hemiarthroplasty, and total hip arthroplasty. The recently completed Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) randomized trial sought to offer insight on those treatment modalities.1 The study enrolled 1,079 patients with low-energy femoral neck fractures and randomized them into treatment with CS or SHS.

In a follow-up study published in the May 2018 edition of the Journal of Orthopedic Trauma, Sprague et al. analyzed FAITH data to identify predictors of revision surgery during 24 months after surgical fixation of a femoral neck fracture.2 Based on previously published studies, the authors identified 15 factors a priori that may be associated with revision surgery . Among the more than 800 patients in the FAITH cohort who had complete follow-up data, 191 (23%) underwent revision surgery and were included in the analysis. Proportional hazard modeling identified 5 factors associated with revision surgery: female sex (hazard ratio [HR], 1.79), body mass index (HR, 1.19—a 19% increased risk of revision for every 5-point increase in BMI), displaced fracture (HR, 2.16), Pauwels type III configuration (HR, 2.13 relative to type II), and poor implant positioning (HR, 2.70). In addition, prefracture dependence on assistive devices for ambulation was significantly associated with a risk of conversion to arthroplasty (p = 0.04), although a hazard ratio was not reported.

These important findings may help guide our decision making for the treatment of femoral neck fractures. First, male patients may be better candidates for surgical fixation of neck fractures than female patients, which probably relates to sex differences in bone density. Thinner patients also may be better candidates for femoral neck fixation, while arthroplasty may be the more reliable option for high-BMI patients.

Second, we have to pick the right fractures to fix. As is well described elsewhere in the literature, a more vertical fracture line (>50°) is more likely to fail with fixation. Additionally, patients with displaced fractures face a significantly higher risk of revision surgery and may be poor candidates for fixation.

Arguably, the most important modifiable risk factor for revision surgery is surgical technique. Unfortunately (and fortunately), in the FAITH study there were too few malreductions to investigate this variable in detail. However, poor implant positioning—defined as prominent screws at the lateral cortex, screw penetration, and lag screws positioned too high—was strongly associated with an increased risk of revision surgery.

It goes without saying, but well-placed implants perform better.

Matthew Herring, MD is a senior orthopaedic resident at the University of Minnesota and a member of the JBJS Social Media Advisory Board.

References

  1. Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017;389(10078):1519-1527.
  2. Sprague S, Schemitsch EH, Swiontkowski M, et al. Factors Associated With Revision Surgery After Internal Fixation of Hip Fractures. J Orthop Trauma. 2018;32(5):223-230.

Fragility Fracture Workshop & Symposium—June 28 & 29, 2018

ownbone_logo-rOn Thursday evening, June 28 and all day Friday, June 29 in Boston, The American Orthopaedic Association (AOA) and the National Association of Orthopaedic Nurses (NAON) will present two educational/networking events concentrating on secondary fragility fracture prevention.

The Thursday evening Workshop, available only to those attending the Friday Symposium, will convene clinicians with expertise in counseling and treating fragility fracture patients. “This new two-hour workshop provides an additional opportunity to learn more about identifying, assessing, counseling, and treating fragility fracture patients,” said program co-chair Debra Sietsema, PhD, RN. “The Workshop also includes special breakout stations on calcium, FRAX, and the AOA’s ‘Own the Bone’ initiative.”

The all-day Symposium on Friday focuses on how to establish a multidisciplinary secondary fragility fracture program. In addition, the Symposium will include relevant case studies demonstrating how to translate the principles into hospital, private-practice, or clinic settings. “This Symposium is a great opportunity for orthopaedic surgeons and allied health professionals to get the full picture in one day,” said Dr. Sietsema. “Attendees will gain both basic and expanded knowledge to put their programs in place.”

Register by May 15 to receive early-bird pricing for these important events. NAON members and clinicians from enrolled Own the Bone institutions save an additional $50.

A Video Approach to Improving Outcomes in Digit Replantation

Anastomosis Refill for OBuzzArterial and venous reperfusion problems are common causes of failure in digit replantation, so excellent vascular anastomotic technique is crucial during these operations. One way to assess the patency of vascular anastomoses intraoperatively is to estimate refilling velocity with the naked eye. An even better way is described by Zhu et al. in the May 2, 2018 edition of The Journal of Bone & Joint Surgery.

The authors divided their study into two phases. During phase I, they found that a slower refilling velocity ratio (RVR) in 103 replanted digits, calculated with the aid of videos recorded at 1,000 frames per second, was associated with replantation failure. In phase II, the authors applied RVR goals established from phase I to another 79 replanted digits to determine whether the additional objective guidance increased the replantation survival rate compared with historical controls.

Based on phase I results, Zhu et al. set the arterial RVR goal to 0.4 and the venous RVR sum goal to 1.0. Using those goals for guidance, the authors found that the phase II success rate (96%) was significantly higher than that among historical controls (87%). In several phase I cases, intraoperative observations of specialists considered anastomoses to be acceptable, but the high-speed video data revealed that improvements were required.

One downside to obtaining this objective video data about anastomotic quality is that it adds 10 to 15 minutes to operative time. Consequently, the authors cite the need for a “well-designed, randomized, double-blinded clinical trial…to provide stronger evidence of this assessment technique.”

Scottish Hip Fracture Treatment Guidelines Improve Outcomes

Hip Fracture for OBuzzIt is easy, perhaps even fun (in a cynical way), to discredit clinical guidelines and suggested care pathways for certain orthopaedic diseases. They are often nuanced, may require a significant change to our practice that we find impractical, and may seem to offer little benefit over current practices. Why change when our patients do just fine with how we have always treated them? Well, as Farrow et al. clearly demonstrate in the May 2, 2018 edition of JBJS, we should follow these guidelines and patient care pathways in hip fracture patients ≥50 years old because patients have better outcomes when we do.

The authors found that increased adherence to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP), implemented in Scotland in 2014,  led to a >3-fold decrease in patient mortality at 1 month and a 2-fold decrease in mortality at 4 months. High levels of adherence to the SSCHFP also led to shorter hospital stays and decreased odds of discharging patients to high-care settings, such as a skilled nursing facility. This cohort study of data collected from  >1,000 patients saw only 8% of the initial population lost to follow-up.

Just as importantly, when the authors ran a multiple regression analysis, they found that no single SSCHFP practice or patient variable was as important as following the total SSCHFP protocol. The authors thus conclude that “the impact of the standards as a whole is greater than the sum of the parts and highlights the importance of a multidisciplinary team approach…” In other words, following the protocol helped improve patient outcomes. Period.

Studies like this by Farrow et al. are important and impactful. Practice guidelines and care criteria are developed with careful attention to the evidence base, but we are just starting to see published data on their effect on outcomes. This makes them difficult to accept because we DO have data (at least anecdotal data) supporting our current practices. It is easier to stick to our known current methods than to adopt new ones, however subtle, that require change and have little accompanying outcomes data.  Implementing practice guidelines will always be challenging, but having data such as these showing the power of their effect should help make adoption easier.

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

Click here to read a press release about this study from the University of Aberdeen.

JBJS 100: Shoulder Impingement and Distraction Osteogenesis

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 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:

Anterior Acromioplasty for Chronic Impingement Syndrome in the Shoulder
C S Neer: JBJS, 1972 January; 54 (1): 41
For many years after its publication, this 1972 JBJS article changed the treatment approach for patients with shoulder disability. But more recently, arthroscopy and magnetic resonance imaging arthrography have identified other painful non-impingement shoulder conditions. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete rotator cuff tear, and performing aggressive rehabilitation prior to corrective surgery.

Use of the Ilizarov Technique for Treatment of Non-union of the Tibia Associated with Infection
G K Dendrinos, S Kontos, E Lyritsis: JBJS, 1995 June; 77 (6): 835
This case series described a technique of bone transport with bridging achieved by distraction osteogenesis. The defects averaged 6 cm, the mean duration of treatment was 10 months, and the mean time to union was 6 months. More recent research has focused on augmenting the osteogenic potential of tissues in the distraction gap with substances such as bone morphogenetic protein, platelet-rich plasma, and mesenchymal stem cells.