Since its introduction in the late 20th century, the 2-stage induced membrane technique has been lauded for its bone-reconstruction advantages over alternatives such as distraction osteogenesis and vascularized bone. The cases presented in this month’s “Case Connections” demonstrate that the technique can work with a variety of bone-defect shapes, sizes, and locations.
The springboard case, from the August 10, 2016 edition of JBJS Case Connector, describes 3 cases of chronic post-infection osteomyelitis in children in whom large diaphyseal defects were successfully treated with the induced membrane technique. Three additional JBJS Case Connector case reports summarized in the article focus on:
- a 50-year-old diabetic man with a necrotic foot ulcer in whom an extensive midfoot defect was successfully treated with this technique
- successful induced-membrane treatment of a 7-year-old girl with congenital pseudarthrosis of the clavicle
- 2 cases of trauma-caused segmental bone loss that were treated successfully with the induced membrane technique
It is imperative to resolve all active infection before or during stage 1 of this procedure, and careful spacer removal prior to stage 2 is of paramount importance to prevent damage to the induced membrane.
One of the newest features from JBJS Reviews is the “Team Approach” article. Team Approach articles highlight the individual and collective importance of the multiple physician and nonphysician providers who are involved in the care of a patient. Determining how the multidisciplinary interactions and contributions are key to the understanding of a medical condition and its treatment can be essential to a successful musculoskeletal health process.
In the July 2016 issue of JBJS Reviews, Pinzur et al. describe the team approach to the treatment of diabetic foot ulcers. The authors note that an estimated 29.1 million people in the U.S. have diabetes and that, at any point in time, 3% to 4% have a foot ulcer, both of which are sobering statistics. Diabetic foot ulcers and their associated infections lead to >70,000 lower-extremity amputations yearly. Between one-third and one-half of diabetic patients undergoing major lower-extremity amputation will die within 2 years after the amputation. In order to most effectively deal with this devastating outcome, a team approach with multidisciplinary involvement is needed.
It is now accepted that the best-performing health systems are those that address challenges by developing a strategy of population management in which patients with resource-consuming medical conditions receive care across multiple medical disciplines. This strategy begins with the identification of modifiable risk factors. The most efficient patient-safety methodology for avoiding complications following surgery is to operate on healthier patients. Indeed, if we look at our orthopaedic trauma colleagues as an example, we see that survival rates and patient outcomes following hip fracture have improved since the development of systems that rapidly optimize patients prior to operative repair. This experience has taught us how important it is to have a hospitalist co-managing our orthopaedic patients. Similarly, our arthroplasty colleagues have learned that outcomes are worse and complications rates are increased in patients who have multiple medical comorbidities. Prior to urgent surgery, many of these medical conditions can be stabilized. Thus, the most proactive health systems are those that use interventions to identify and minimize health risk. When modifiable risk factors are improved, patient safety is improved.
Pinzur et al. reintroduce the concept of the so-called diabetic educator. The responsibilities of the modern diabetic educator have progressed from simple patient education on diet, glycemic control, and lifestyle change to using the educator-patient relationship to empower the educator to serve as a patient navigator/case manager. The diabetic educator and the physician also work closely with a certified pedorthist. This provider’s knowledge and skill of health maintenance through the use of therapeutic footwear are important in the prevention and treatment of diabetic foot ulcers. Patients are taught to self-examine their feet, and this level of empowerment becomes important from a psychosocial perspective.
The primary surgeon is the “captain of the ship,” and it is his or her responsibility to coordinate the management and the function of the multidisciplinary team. It is important to identify the roles of the consultants such as the certified pedorthist (who will provide guidelines on therapeutic footwear and prefabricate a custom foot orthosis as needed), the vascular surgeon (who will be needed for patients with a nonhealing foot ulcer and a nonpalpable pedal pulse), the radiologist (who will be essential for suggesting imaging modalities for understanding the disease and its progression), the infectious disease specialist (who will guide duration of therapy and monitor associated antibiotic-induced organ-system morbidity), and the plastic surgeon (who may have unique requirements for wound care and developing relationships in clinical-care algorithms).
The multidisciplinary team approach involves the use of a consistent strategy throughout the hospital or health system. This is the first step in an attempt to decrease the negative impact on quality of life and resource consumption and is essential to diabetic foot care.
Thomas A. Einhorn, MD
Editor, JBJS Reviews