In the July 1, 2020 issue of The Journal, Dr. C. McCollister Evarts, writes an illuminating “What’s Important” essay about learning from his most difficult cases. He recounts an event early in his career as a medical officer aboard an aircraft carrier, when a fat embolism caused the untimely death of a young adult patient he treated for a closed tibial fracture. This event spurred a lifelong quest for knowledge about surgery-associated emboli, about which cases and literature were sparse at the time (mid-1960s). My quick search of Dr. Evarts’ long list of publications shows that more than 20 of them are related to embolic events, no doubt a direct result of the experience with that seaman many years ago, and with another one of his early-career patients who died of a pulmonary embolism a week after undergoing hip surgery.
We should all look toward our patients to teach us ways to improve our craft. Not every procedure goes as planned, and the day a surgeon stops trying to get better should likely be the day he or she starts contemplating retirement. Dr. Evarts states that “each and every encountered complication should be carefully examined with the goal of ultimately providing better care.”
Instead of fearing complications, orthopaedic surgeons should carefully analyze the root causes of complications as part of their career-long effort to learn and improve. Our patients can be our teachers in these difficult situations, and we should be willing and open students. This teacher-student approach might require a difficult conversation with the patient or their family to understand why the procedure didn’t go as planned or the outcomes weren’t what was envisioned. As Dr. Evarts points out in his essay, “Most family members do not understand what has happened when a complication occurs, and they appreciate an explanation in a face-to-face meeting.”
The adage that “you learn something new every day” is more likely to come true if you pay extra attention to your most difficult cases. As practicing surgeons, we are never “finished.” We should strive to remain teachable students, always learning from our patient-teachers.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Surgeons performing revision shoulder arthroplasty typically order postoperative antibiotics to be administered while they wait for results from intraoperative cultures. Based on their index of suspicion from preoperative exams and intraoperative observations, they order either intravenous (high suspicion of infection) or oral (low suspicion) antibiotics during the waiting period. In the June 3, 2020 issue of JBJS, Yao et al. report on a retrospective review of 175 patients who underwent revision shoulder arthroplasty, finding that surgeons’ presumptive choice of antibiotic type matched the culture results in 75% of the cases.
Among the 175 patients in the study, IV antibiotics were initiated in 62, while 113 patients received oral antibiotics. Cultures from 49 of the 62 patients started on IV antibiotics came back positive, and cultures from 83 of the 113 patients started on oral antibiotics came back negative. Treatment of patients whose initial antibiotic regimen did not match culture results was modified accordingly.
After multivariate analysis Yao et al. found that male sex, prior ipsilateral infection, and intraoperative presence of a humeral membrane were 3 independent predictors of surgeons initiating IV antibiotics. Antibiotic-related adverse events (including GI, dermatologic, and allergic reactions) occurred in 19% of the patients. Not surprisingly, the rate of these complications was highest among those receiving IV antibiotics.
Although the surgeons’ empirical initiation of antibiotic administration route was “correct” 75% of the time, that still left 25% of the patients needing modification of therapy based on culture results. While the authors observe that their study was not designed “to report the relative effectiveness of the 2 antibiotic protocols in minimizing the risk of recurrent infection,” their findings confirm that preoperative and intraoperative observations can help surgeons select the “right” type of antibiotic without culture results—and that is heartening.
Orthopaedic surgeons work hard to find good alternatives to total hip arthroplasty (THA) in patients <50 years old. That’s because the high functional demands and longer remaining lifespan in these patients can result in excessive wear of the bearing surfaces and loosening of the components—both of which have been documented in multiple publications. But what happens when THA is the most viable solution for a posttraumatic or congenital hip problem in a very young patient because arthrodesis or other osteotomies are not feasible?
In the March 18, 2020 issue of The Journal, Pallante et al. report medium-term outcomes of THA in 78 patients who were ≤20 years of age at the time of surgery, with follow-ups ranging from 2 to 18 years. The findings included the following:
- 10-year survivorship for reoperation of 95.0%
- 10-year survivorship for revision of 97.2%
- 10-year survivorship for complications of 89.5%
Overall, the linear articular wear averaged 0.019 mm/yr in the ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene bearings studied, and the average modified Harris hip score in the cohort was 92.
However, despite these impressive clinical and survivorship outcomes, I advise orthopaedists not to lower their resistance to performing THA on these very young patients, many of whom present with hip problems caused by deforming conditions such as Legg-Calve-Perthes disease. We really need 30 to 40 years of outcome data to truly understand what happens with function, revision rates, and wear characteristics in this population. Having said that, I am confident that this group from Mayo will continue reporting on this patient cohort at 5- to 10-year intervals, so that the worldwide orthopaedic community can keep learning from this experience.
Marc Swiontkowski, MD
In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”
Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.
This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).
Specifically, on the clinical side, Farley et al. found the following:
- A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
- A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
- A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)
Here are the findings from the resource-utilization side:
- A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
- A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”
Sometimes the findings of well-designed orthopaedic studies are unexpected and counterintuitive—and sometimes they are not. In the latter category are the important but unsurprising results from the Grace et al. database study in the February 19, 2020 issue of The Journal of Bone & Joint Surgery.
The authors set out to determine whether having a specific medical complication after a first total knee arthroplasty (TKA) increased the chance that the same complication would occur after a second TKA performed 90 to 365 days after the first one. Among the specific complications investigated were myocardial infarction (MI), ischemic stroke, respiratory complications, urinary complications, digestive complications, hematoma, deep vein thrombosis (DVT), and pulmonary embolism (PE).
Overall complications after either procedure were low—>90% of the >36,200 patients who underwent bilateral TKAs did not experience any complications during the study period. However, those who had a complication after the first TKA had a significantly higher likelihood of having the same complication after the subsequent, contralateral procedure. Expressed as odds ratios (ORs), the increased probabilities of the same complication recurring after the second procedure were as follows:
- Myocardial infarction—OR, 56.63
- Ischemic stroke—OR, 41.38
- Hematoma—OR, 15.05
- Urinary complications—OR, 11.19
- PE—OR, 11.00
- Respiratory complications—OR, 8.58
- Non-MI cardiac complications—OR, 7.73
- DVT—OR, 7.40
Noting that these findings do not imply causality, the authors nevertheless surmise that “the occurrence of complications after the first replacement likely reflects a burden of comorbidity that predisposes patients to a recurrence of the same complications after the second replacement.” Consequently, Grace et al. suggest that this data could be used to help guide shared decision-making with patients considering staged bilateral TKAs, and that these findings could help identify “a subgroup of patients who may benefit from…targeted optimization strategies prior to the second surgical procedure.”
Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.
In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.
At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.
Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
- Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.
Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures:
- “Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
- How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
- Immobilization after Fixation of Distal Radial Fractures
- Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
- Fixation Costs for Distal Radial Fracture
- Plate–Tendon Contact: How Important Is It?
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
In the December 6, 2017 issue of The Journal, Arshi et al. report on a detailed analysis of a large administrative database, looking specifically at one-year complications associated with outpatient versus standard inpatient knee replacement. This type of analysis is crucial because of the rapidly growing interest in outpatient joint replacement among patients, payers, and the orthopaedic community.
The data convince me that these outpatient procedures should proceed, but with a little more caution. Although the absolute complication rates in both surgical settings were very low, after adjusting for age, sex, and comorbidities, the authors found a higher relative risk of several surgical and medical complications among outpatients—including component failure, infection, knee stiffness requiring manipulation under anesthesia, and deep vein thrombosis.
One important element that is lacking in this analysis is adjustment for surgeon/hospital volume. We know from important work by Katz and others that patients managed at centers and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events.
These results from Arshi et al. are definitely not a call to stop the expansion of outpatient joint replacement protocols. Instead, I think this study should prompt every joint-replacement center to analyze its risk-adjusted inpatient and outpatient outcomes—and to ensure, as these authors emphasize, that outpatients receive the same level of attention to rehabilitation, antibiotic administration, and thromboprophylaxis as inpatients.
Enhancing outpatient knee-replacement protocols will serve local communities well, and the nationwide orthopaedic community will receive further confirmation that outpatient joint replacement is a move in the right direction.
Marc Swiontkowski, MD
Patients with diabetes have an increased risk of postoperative complications following total joint arthroplasty (TJA). Additionally, perioperative hyperglycemia has been identified as a common and independent risk factor for periprosthetic joint infection, even among patients without diabetes. Therefore, knowing a patient’s glycemic status prior to surgery is very helpful.
In the November 15, 2017 edition of The Journal of Bone & Joint Surgery, Shohat et al. demonstrate that serum fructosamine, a measure of glycemic control obtainable via a simple and inexpensive blood test, is a good predictor of adverse outcomes among TJA patients—whether or not they have diabetes.
Researchers screened 829 patients undergoing TJA for serum fructosamine and HbA1c—a common measure, levels of which <7% are typically considered good glycemic control. Patients with fructosamine levels ≥292 µmol/L had a significantly higher risk of postoperative deep infection, readmission, and reoperation, while HbA1c levels ≥7% showed no significant correlations with any of those three adverse outcomes. Among the 51 patients who had fructosamine levels ≥292 µmol/L, 39% did not have HbA1c levels ≥7%, and 35% did not have diabetes.
In addition to being more predictive of postsurgical complications than HbA1c, fructosamine is also a more practical measurement. A high HbA1c level during preop screening could mean postponing surgery for 2 to 3 months, while the patient waits to see whether HbA1c levels come down. Fructosamine levels, on the other hand, change within 14 to 21 days, so patients could be reassessed for glycemic control after only 2 or 3 weeks.
While conceding that the ≥292 µmol/L threshold for fructosamine suggested in this study should not be etched in stone, the authors conclude that “fructosamine could serve as the screening marker of choice” for presurgical glycemic assessment. However, because the study did not examine whether correcting fructosamine levels leads to reduced postoperative complications, a prospective clinical trial to answer that question is needed.
In the November 15, 2017 issue of The Journal, Courtney et al. carefully evaluate CMS data to compare TKA and THA costs, complications, and patient satisfaction between physician-owned and non-physician-owned hospitals. The authors used risk-adjusted data when comparing complication scores between the two hospital types, in an attempt to address the oft-rendered claim that surgeons at physician-owned facilities “cherry pick” the healthiest patients and operate on the highest-risk patients in non-physician-owned facilities.
In general, the findings suggest that, for TKA and THA, physician-owned hospitals are associated with lower costs to Medicare, fewer complications and readmissions, and superior patient-satisfaction scores compared with non-physician-owned hospitals. These findings should come as no surprise to readers of The Journal. One fundamental principle of health care finance is that physicians control 70% to 80% of the total cost of care with their direct decisions. When physician incentives are aligned with those related to the facility, the result is better care at lower cost.
Nevertheless, many policymakers remain convinced that physician-owners are completely mercenary and base every decision on maximizing profit margins—even if that includes ordering unnecessary tests, performing unnecessary procedures, or using inferior implants. We need more transparency among physician-owners at local and national levels to address these usually-erroneous assumptions, which are frequently repeated by local non-physician-owned health systems. For example, we should be transparent with the percentage of the margin that ends up in the physician-owner’s pocket. Whatever the “right” percentage is, I believe it should not be the dominant factor in a physician’s total income..
The findings from Courtney et al. should spur further debate on this issue. I am confident that the best outcomes for individual patients and the public result when physicians (and their patients) stay in direct control of decision making regarding care, when surgeons are appropriately motivated to be cost- and outcome-effective, and when we all do our part to care for the under- and uninsured.
Marc Swiontkowski, MD