Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center
Full Article
Overlapping surgery occurs when a single surgeon is the primary surgeon for >1 patient in separate operating rooms simultaneously. The surgeon is present for the critical portions of each patient’s operation although not present for the entirety of the case. While overlapping surgery has been widely utilized across surgical subspecialties, few large studies have compared the safety of overlapping and nonoverlapping orthopaedic surgery.
Keeping Your Bones Pumped Up
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.
While a reasonable amount of “pumping iron” exercise has proven beneficial for musculoskeletal health, long-term use of acid-suppressing proton pump inhibitors (PPIs) may have the opposite effect on bone. Many people are currently taking PPIs, most commonly for gastrointestinal disorders such as heartburn and gastroesophageal reflux. Fortunately, many are occasional PPI users, taking the drugs only when symptoms arise. However, PPIs are often prescribed long term for preventive reasons.1
The same proton-pump mechanism present in the GI tract is seen in the vacuolar H+-ATPases that are present in high concentrations on the ruffled border of osteoclasts.2 Years of PPI use may therefore interfere with normal and essential bone remodeling. PPIs are also prescribed in the pediatric population for reflux symptoms. The effect of PPIs on future fracture or long-term osteoporosis in these very young patients is not clear.
The consequences for adult and elderly patients are clearer. Femoral bone mineral density is significantly decreased in PPI users. Also, patients with peptic ulcer disease using PPIs have a higher risk for osteoporosis than peptic ulcer patients not using PPIs. Among younger adults, the risk of fracture was significantly higher in those using PPIs than in those not using PPIs.
In 2010, the FDA issued a communication alerting healthcare professionals that users of PPIs have a possible increased risk of fractures of the hip, wrist, and spine, and that they should weigh the known benefits against the potential risks when recommending use of these medications. In 2011, the FDA refined its language somewhat: “Following a thorough review of available safety data, FDA has concluded that fracture risk with short-term, low dose PPI use is unlikely.” Still, when fractures are the outcome of interest, the data implicates long-term use of PPIs in having deleterious effects on bone.
Although data on human fracture healing in association with PPI use are sparse, animal studies do show that PPIs have a negative impact on normal fracture healing, with a decrease in the expression of important markers of bone formation, including bone morphogenetic protein (BMP)-2, BMP-4, and cysteine-rich angiogenic inducer (CYR)61.
It is time to question the need for chronic use of PPIs by our patients. Orthopaedists should encourage their patients who take PPIs to discuss this matter with their primary care physician.
References
- Eom CS, Park SM, Myung SK, Yun JM, Ahn JS. Use of acid-suppressive drugs and risk of fracture: a meta-analysis of observational studies. Ann Fam Med. 2011 May-Jun;9(3):257-67. doi: 10.1370/afm.1243. PMID: 21555754
- Wagner SC. Proton Pump Inhibitors and Bone Health: What the Orthopaedic Surgeon Needs to Know. JBJS Rev. 2018 Dec 18. doi: 10.2106/JBJS.RVW.18.00029. [Epub ahead of print] No abstract available. PMID: 30562209
Using CT Data to Diagnose Osteoporosis
Osteoporosis is a “silent” disease, often becoming apparent only after a patient older than 50 sustains a low-energy fracture of the wrist, proximal humerus, or hip. Monitoring serum vitamin D levels and DEXA testing represent ideal screening methods to prevent these sentinel fragility fractures. In addition, through programs such as the AOA’s “Own the Bone” initiative, the orthopaedic community has taken a leadership role in diagnosing and treating osteoporosis after the disease presents as a fragility fracture. Own the Bone is active in all 50 states and, through local physician leadership, is identifying individuals who present with a fragility fracture so they can receive follow-up care that helps mitigate bone loss and prevent secondary fractures.
We still have a long way to go, however. Recent analyses show that only 30% of candidate patients (albeit up from 20%) are receiving this type of evidence-based care. The best-case scenario would be to identify at-risk men and women (osteoporosis does not affect women exclusively) before a potentially serious injury.
In the December 5, 2018 issue of The Journal, Anderson et al. present strong evidence that computed tomography (CT) can provide accurate data for diagnosing osteoporosis. CT is increasingly used (perhaps overused in some settings) across a spectrum of diagnostic investigations. The osseous-related data from these scans can be used to glean accurate information regarding a patient’s bone quality by analyzing the Hounsfield unit (HU) values of bone captured opportunistically by CT. HU data are routinely ignored, but the values correlate strongly with bone mineral density, and they could help us recommend preventive care to our patients before a fragility fracture occurs. (For example, a threshold of <135 HU for the L1 vertebral body indicates a risk for osteoporosis.)
Orthopaedists should discuss the possibility of asking their radiologist colleagues who read CT scans of older patients to routinely share that data. When indicated, we could promptly refer patients back to their primary care provider for discussion of pharmacological treatment and lifestyle changes proven to help prevent primary fragility fractures. There is little doubt that our patients are getting older. Reviewing CT data could help us dramatically improve preventive care and decrease the risk of first-time fragility fractures.
Click here for additional OrthoBuzz posts about fragility fractures.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Residents in the OR—What’s the Risk?
Orthopaedic educators have long confronted the subtle implication that resident participation in surgical care can contribute to patient harm or even death. While there have been numerous changes in residency education to improve the supervision and training of residents, the reality is that surgical trainees have to learn how to operate. This fact can leave surgical patients understandably nervous, and many of them heave heard rumors of a “July effect”—a hypothetical increase in surgery-related complications attributed to resident education at the beginning of an academic year. To provide further clarity on this quandary, in the November 21, 2018 issue of The Journal, Casp et al. examine the relationship between complication rates after lower-extremity trauma surgery (for hip fractures, predominantly), the participation and seniority of residents, and when during the academic year the surgery occurred.
The authors used the NSQIP surgical database to examine >1,800 patient outcomes after lower-extremity surgery according to academic-year quarter and the postgraduate year of the most senior resident involved in the case. The analysis revealed two major findings:
- Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
- Cases involving more senior residents were associated with an increased risk of superficial surgical site infection during the first academic quarter.
While the authors were unable to provide a precise reason for the second finding, they hypothesized that it could have been related to more stringent data collection early in the academic year, senior-resident inexperience with newly increased responsibilities, or the warm-temperature time of year in which the infections occurred. Casp et al. emphasize that the database used in the study was not robust in terms of documenting case details such as complexity and the degree of resident autonomy, which makes cause-and-effect conclusions impossible to pinpoint.
Although this large database study does not answer granular questions regarding the appropriate role of residents in orthopaedic surgery, it should stimulate further research in this area. Gradually increasing responsibility is necessary within residency programs so that residents develop the skills and decision-making prowess necessary for them to succeed as attending surgeons. Studies like this help guide future research into the important topic of graduate medical education, and they provide patients with some reassurance that the surgical care they receive is not affected by the time during the academic-calendar year in which they receive it.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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
Under 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
Until 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
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
- 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
Diagnosing 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
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.
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
- 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
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