Rehabilitation Strategies: Fertile Ground for Prospective Randomized Trials
Approximately 18% of JBJS scientific studies published in 2020 were Level I or II investigations. The number of high-level studies has continued to grow slowly year over year. In terms of randomized controlled trial design, we have found that the facets of care that are often the focus of study are those that are most straightforward—the use of tourniquets, resurfacing the patella with total knee arthroplasty, intraoperative and postoperative drug therapies, as examples. One under-investigated area is rehabilitation, as far as both management strategies post-injury and more detailed, comprehensive post-surgical programs.
In the latest issue of JBJS, Martínez et al. evaluate the question of duration of sling use following proximal humeral fracture in patients managed nonoperatively. This is an important patient centric question that has largely been informed by “hand me down” prescriptions from residency teaching faculty. In a very well-designed Level II trial involving an adult cohort (mean age of 70; range, 42 to 94 years), they found no significant differences in pain and function between patients randomized to 1 week of immobilization versus 3 weeks of immobilization. In addition, no significant difference in the complication rate was found.
Pain was assessed using a visual analog scale at 1 week and 3 weeks after fracture and then at the 3, 6, 12, and 24-month follow-up. Functional outcome was evaluated using the Constant score, and functional disability was evaluated with the Simple Shoulder Test, a self-reported questionnaire; both of these measures were recorded at the 3, 6, 12, and 24-month evaluation. No differences in pain and function at any time point were observed.
Many readers of JBJS have had the experience of patients abandoning the sling as soon as they are comfortable, regardless of what our original instructions were, so the findings of this study are relatable. The authors concluded that, “These fractures can be successfully managed with a short immobilization period of 1 week in order not to compromise patients’ independence for an extended period.”
It strikes me that there are numerous rehabilitation prescriptions that are ripe for evaluation using a randomized design. (Wear an orthosis when sleeping? Keep it on at all times or only when walking? Etc.) Let’s get after these questions in the manner of Martinez et al. as we seek to give our patients solid evidence to back our instructions.
A downloadable JBJS infographic regarding this study can be found here.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Sustainable Trauma Care in Low-Resource Settings: How Can We Help?
Orthopaedic colleagues who live and practice in low-resource areas around the world have clearly voiced that they want support from better-resourced partners. But such efforts must be sustainable, a key point emphasized by Woolley et al. in their thought-provoking 2019 JBJS “What’s Important” essay regarding orthopaedic care in Haiti. In contrast to “medical missions” offering short-term assistance for a small number of patients, longer-term systemwide gains come from partnerships focused on education and training that acknowledge the central role of local orthopaedic practitioners in addressing the ongoing needs of their patients.
Along those lines, Agarwal-Harding et al. describe a 3-phase pathway for improving ankle-fracture management in sub-Saharan Malawi in their recent JBJS report. In the first 2 phases, the local knowledge base and treatment strategies were assessed. (Greater than 90% of orthopaedic trauma care in the country is provided by nonphysician “clinical officers,” and most ankle-fracture management in Malawi is nonoperative because there is only about 1 orthopaedic surgeon per 1.9 million Malawians). A team of Malawian and US faculty then designed and implemented an education course that reviewed ankle anatomy, fracture classification, and evidence-based treatment guidelines. From that arose standardized protocols to improve fracture-care quality and safety in the face of limited resources.
While these protocols were unique to the Malawian context, I am convinced that similar interventions can be adapted for other low-resource environments—as long as local clinicians are part of the process. With such a flexible and sustainable program in place, efforts can then be directed toward the advancement of surgical skills and development of cost-effective supply chains. We should all support such efforts worldwide, recognizing that the burden of musculoskeletal trauma is a public health issue warranting collaborative solutions with lasting impact.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Click here for a related OrthoBuzz post about trauma care in Malawi.
A Rare Innovation in Pediatric Orthopaedics
True innovation—improvement way beyond the incremental—is rare in orthopaedics, whether it’s pre- and postoperative management, surgical technique, or prosthetic design. Innovation is even rarer, understandably, in addressing conditions that themselves are rare. Rarer still are innovations in treating pediatric conditions because of the many different congenital etiologies that don’t present in sufficient numbers to meaningfully study interventions.
Congenital pseudarthrosis of the tibia is one such rare pediatric condition, and it is one of the most challenging problems facing pediatric orthopaedic surgeons. In its pre-fracture state, this condition is called congenital tibial dysplasia or anterolateral bowing of the tibia. The goal of treatment at this stage is preventing fracture in the dysplastic, bowed area, because post-fracture union is difficult to achieve and maintain—and because chronic nonunion puts patients at risk for long-term pain, deformity, and disability.
In the December 2, 2020 issue of The Journal, Laine et al. present results of a simple outpatient surgical solution to this problem in 10 pediatric patients who were followed for an average of 5 years. Using a limited-exposure, plate-and-screw approach to control physeal growth, these authors produced correction in tibial alignment in all 10 patients. Most importantly, no patient developed a tibial fracture or pseudarthrosis after the guided-growth procedure, which also improved radiographic appearance of dysplastic bone and preserved leg length. Although 6 of the 10 patients required a plate exchange, the authors’ institution now offers this procedure as first-line treatment to all patients presenting with pre-fracture congenital tibial dysplasia.
Congenital bowing of the tibia is a condition that will probably never be subject to a controlled clinical trial due to the (fortunately) low number of patients affected. However, carefully conducted small cohort studies such as this can reveal true innovation that advances care for small but very vulnerable populations.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
The NSAID-Fracture Nonunion Debate Continues
Many animal studies have investigated the impact of nonselective NSAIDs and selective COX-2 inhibitors on fracture healing. Nearly all those experiments focused on chronic drug administration following simulated long-bone fractures. One concern regarding the clinical relevance of those animal studies is that the “fractures” are often created by open means, which results in cortical devascularization and which may not accurately simulate the most common long-bone fracture pathophysiology in humans. Nevertheless, many orthopaedic surgeons have used the results of those animal studies to limit—or even stop—their use of NSAIDs to treat postfracture pain.
In the July 15, 2020 issue of The Journal, George et al. use a large private-insurance database to investigate the association between postfracture prescriptions filled for NSAIDS (both selective COX-2 inhibitors and nonselective types) and the subsequent diagnosis of a nonunion at 1 year postinjury. Administrative database research is more useful for generating hypotheses than for proving or disproving them, and these authors (along with Commentary writer Willem-Jan Metsemakers, MD, PhD) rightly point out that adequately powered randomized trials are needed to more fully address this issue.
Still, I was a bit surprised by the finding that nonselective NSAIDs were not associated with the diagnosis of nonunion while selective COX-2 inhibitors were. It seems to me that, given the sparse and conflicting clinical evidence today, a brief course of NSAIDs for fracture-related pain management should be included for patients while we await answers from studies with more robust research designs.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Managing Fractures in Patients with COVID-19
As JBJS Editor-in-Chief Marc Swiontkowski, MD observed in a recent editorial, some musculoskeletal health professionals “have been set aside to some degree” during the COVID-19 pandemic. However, Dr. Swiontkowski also emphasized that “emergency/urgent procedures [still] need to be carried out.” Which leads to the question: What are the best medical practices for patients who have both fracture and COVID-19 infection.
To help answer that question, JBJS fast-tracked the publication of an article by Mi et al., which retrospectively reviewed the medical records of 10 patients from 8 hospitals in China who had both a bone fracture and COVID-19 infection.
Presenting Symptoms
All of the fractures were caused by accidents, most of them low-velocity. Flu-like symptoms of patients with a fracture and COVID-19 disease were diverse, as follows:
- 7 patients (70%) reported fever, cough, and fatigue.
- 4 (40%) had a sore throat.
- 5 (50%) presented with dyspnea.
- 3 (30%) reported dizziness.
- 1 patient (10%) reported chest pain, nasal congestion, and headache.
- 1 patient (10%) reported abdominal pain and vomiting.
Imaging and Lab Results
Six of the 10 patients were positive for SARSCoV-2 based on quantitative reverse transcription polymerase chain reaction (qRT-PCR) of throat-swab samples. All patients ultimately showed evidence of viral pneumonia on computed tomography (CT) scans, but on admission 3 patients did not exhibit severe symptoms or have obvious evidence of COVID-19 on CT scans, and they therefore underwent a surgical procedure. Fever and fatigue signs were observed in these 3 patients after the operation.
The overall results of laboratory tests were as follows:
- 6 patients had lymphopenia (<1.0 x 109 cells/L)
- 9 patients had a high level of C-reactive protein.
- 9 patients had D-dimer levels that exceeded upper normal limits. The authors suggest that this finding “could represent the special laboratory characteristics of fractures in patients with COVID-19.”
Management
Three of the 10 patients underwent surgery; the others were managed nonoperatively due to their compromised status.
All patients received antiviral therapy and antibacterial therapy, and 9 patients were managed with supplemental oxygen. None of the patients received invasive mechanical ventilation or extracorporeal membrane oxygenation because of local limitations in medical technology.
Outcomes
Four patients died in the hospital. Among those who died, surgery had been performed on 1. The clinical outcomes for the 6 surviving patients have not yet been determined.
Conclusions
Because 7 of the 10 patients were determined to have developed a nosocomial infection, the authors emphasize the need “to adopt strict infection-control measures…Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles.”
Mi et al. propose the following 3 additional strategies for patients with a fracture and COVID-19 pneumonia:
- Consider nonoperative treatment for older patients with fractures, such as distal radial fractures, in endemic areas.
- Give patients with a fracture and COVID-19 pneumonia more intensive surveillance and treatment.
- Perform surgery on patients with a fracture and COVID-19 pneumonia in a negative-pressure operating room.
Strong Case for Outpatient Fracture Surgery
Nobody wants to be hospitalized. Hospitals are expensive, risky, and noisy environments, providing probably the worst set-up for restorative sleep. Add to that the issue of health care costs, and it becomes imperative to investigate ways to identify patients and procedures that can be safely moved to the outpatient environment.
Addressing that imperative was the aim of a time-series study in the January 15, 2020 issue of The Journal by Wolfstadt et al. The authors report on the success of a streamlined pathway for safely shifting less-urgent fracture cases to an outpatient environment.
Using the interventions described in the study, a large, urban academic hospital in Canada increased the percentage of fracture patients managed as outpatients from 1.6% pre-intervention to 89.1% post-intervention. None of the >300 patients had a readmission during the intervention period, and there were no complications while patients waited for surgery at home. Although the average time-to-surgery increased to 48 hours after the pathway was implemented, the extra time waiting at home did not negatively affect patient-satisfaction scores.
On the cost/resource side, the hospital estimated that conversions to outpatient care in these patients led to an annual reduction in operating costs of nearly $240,000 CAD. The hospital used the bed capacity freed up by the outpatient fracture pathway to increase its volume of elective hip and knee replacements.
It has been suggested that 90% of orthopaedic procedures can be safely performed in non-hospital environments. Wolfstadt et al. emphasize that successfully doing so requires extra patient education, a team-based and patient-centered culture, and support from hospital administrators.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
The Economics of Revision THA for Fractures: Sustainable?
At the risk of economic oversimplification, it is difficult to sustainably provide a service when payment for it is less than the cost to perform it. But that is one reality exposed by Hevesi et al. in the May 15, 2019 issue of The Journal. Using National Inpatient Sample and ACS-NSQIP data, the authors compared the average costs and 30-day complication rates for revision total hip arthroplasties (THAs) performed for 3 different indications—fractures, wear/loosening, and instability—at both a local and national level. They found that the average hospitalization costs associated with a revision THA related to a fracture were 33% to 48% higher (p < 0.001) than the cost of revision THAs related to wear or instability.
However, the authors emphasize that all 3 of these indications for revision THA are reimbursed at the same rate based on Medicare Diagnosis-Related Group (DRG) codes. DRGs take into account patient comorbidities to determine reimbursement levels—but they do not adjust payments for THA revision according to indication. Hevesi et al. note that the only DRG reimbursement level that would cover the average cost of a revision THA for a fracture would be one performed on a patient with severe medical comorbidities or a major complication. Not surprisingly, patients who underwent a revision THA to treat a fracture were found to have a higher age and more medical comorbidities than those undergoing a revision for wear or instability.
The authors use this data to make a very compelling case that DRGs for revision THA should be changed so they are indication-specific, taking into account the underlying reason for the revision. They observe that “a DRG scheme that does not distinguish between indications for revision THA sets the stage for disincentivizing the care of fracture patients and incentivizing referrals to other facilities.” Those “other facilities” usually end up being large tertiary-care centers, which the authors claim “perform a higher percentage of the costlier revision THA indications.”
This problem of reimbursement inequality is not unique to revision THAs and requires further investigation in many fields. Unless “the system” addresses these subtle but important differences, tertiary referral centers may be inundated with patients who need procedures that cost more to perform than the institutions receive in reimbursement—an unsustainable scenario.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
In My Hands, There’s a Dog Leash
As a journalist covering symposia at the 2019 AAOS Annual Meeting last week, I repeatedly heard the phrase “in my hands…,” referring to a surgeon’s individual experience with this or that technique. That got me to thinking about a research letter published in the March 6, 2019 issue of JAMA Surgery. This retrospective cross-sectional analysis of emergency department data revealed that the annual number of patients ≥65 years old presenting to US emergency departments with fractures associated with walking leashed dogs more than doubled during 2004 to 2017. Women sustained more than three-quarters of those fractures, and while the hip was the most frequently fractured body part, collectively, the upper extremity was the most frequently fractured region. Slightly more than one-quarter of those patients were admitted to the hospital.
The authors rightly pinpoint the “gravity of this burden”; the hip-fracture data alone are worrisome. And in a related online article by hand and wrist surgeons from Rush University Medical Center (titled “Doggy Danger”), the focus is on the many injuries that the human leash-holding apparatus can sustain. The authors of the JAMA Surgery research letter and the Rush authors offer common-sense advice for all us older dog walkers out there, including:
- Dog obedience training that teaches Bowser not to pull or lunge while on leash
- Selection of smaller dogs for older people contemplating acquiring a canine companion
- Holding the leash in your palm, not wrapping it around your hand
- Paying attention to where you walk, and being situationally aware (That means not texting while your dog is momentarily sniffing to see who peed on that post.)
- Selecting footwear that is appropriate for the terrain and environmental conditions during your walk
To these tidbits I would add finding a safe area where your dog can “be a dog” off-leash, preferably with other dogs and people. Socializing is good for both species, and most dog trainers and owners agree that “a tired dog is a good dog.”
The research letter states that a “risk-benefit analysis with respect to dog walking as an exercise alternative is essential,” and the authors do a concise job of quantifying fracture risk and suggesting risk-reduction strategies. The list of benefits from dog walking is too long to itemize here; suffice to say that the advantages run the gamut from physical to mental to spiritual. But let’s be safe and sensible out there. We owe it to our families (dogs included, of course) and to all those overworked orthopaedic trauma surgeons to stay on the sidewalks and in the forests and fields–and out of the ER.
Lloyd Resnick
JBJS Developmental Editor
Keeping a Clinical Eye on Downstream Costs
Medical economics has progressed to the point where musculoskeletal physicians and surgeons cannot ignore the financial implications of their decisions. Unfortunately, in most practice locations it is difficult, if not impossible, to ascertain the downstream costs to patients and insurers of our postsurgical orders for imaging, laboratory testing, and physical therapy (PT). In the April 18, 2018 issue of The Journal, Egol et al. present results from a well-designed and adequately powered randomized trial of outcomes after patients with minimally or nondisplaced radial head or neck fractures were referred either to outpatient PT or to a home exercise program focused on elbow motion.
At all follow-up time points (from 6 weeks to an average of 16.6 months), the authors found that patients receiving formal PT had DASH scores and time to clinical healing that were no better than the outcomes of those following the home exercise program. In fact, the study showed that after 6 weeks, patients following the home exercise program had a quicker improvement in DASH scores than those in the PT group.
The minor limitations with this study design (such as the potential for clinicians measuring elbow motion becoming aware of the treatment arm to which the patient was assigned) should not prevent us from implementing these findings immediately into practice. Each patient going to physical therapy in this scenario would have cost the healthcare system an estimated $800 to $2,400.
I wonder how many other pre- and postsurgical decisions that we routinely make would change if we had similar investigations into the value of ordering postoperative hemoglobin levels, surgical treatment of minimally displaced distal fibular fractures, routine postoperative radiographs for uncomplicated hand and wrist fractures, and PT after routine carpal tunnel release. These are just some of the reflexive decisions we make on a daily basis that probably have little to no value when it comes to patient outcomes. Whenever possible, we need to think about the downstream costs of such decisions and support the appropriate scientific evaluation of these commonly accepted, but possibly misguided, practices.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Orthopaedic Trauma
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 5, 2017 Specialty Update on orthopaedic trauma, selected the five most clinically compelling findings from among the 34 studies summarized in the Specialty Update.
Tibial Fractures
A randomized, sham-controlled clinical trial1 failed to demonstrate improved functional recovery or accelerated radiographic healing with the addition of low-intensity pulsed ultrasound (LIPUS) to the postoperative regimen of fresh tibial fractures.
Postsurgical Weight-Bearing
Two studies support early weight-bearing (WB) after certain operatively managed lower extremity injuries, an allowance that may substantially improve a patient’s early independence. One randomized study2demonstrated that immediate WB after locked intramedullary fixation of tibial fractures is not inferior in union time, complication rates, or early function score when compared with a 6-week period of non-WB. The second randomized trial3 found early WB after select ankle fracture fixation (no syndesmosis or posterior malleolar fixation included) resulted in no increase in complications, fewer elective implant removals, and improved 6-week function, relative to late weight-bearing.
Pelvic Injuries
The addition of posterior fixation to anterior fixation for patients with anteroposterior compression type-2 injuries (symphysis disruption, unilateral anterior sacroiliac joint widening) improved radiographic results and led to fewer anterior plate failures.
Hip Fractures
Less femoral neck shortening occurred with cephalomedullary nail fixation devices (2 mm) than with a side plate and lag screw construct (1 cm) when treating OTA/AO 31-A2 intertrochanteric fractures (unstable, 3 or more parts) in patients ≥55 years of age, although functional outcomes were similar for the two groups.
References
- Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH; TRUST Investigators writing group. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ. 2016 ;355:i5351.
- Gross SC, Galos DK, Taormina DP, Crespo A, Egol KA, Tejwani NC. Can tibial shaft fractures bear weight after intramedullary nailing? A randomized controlled trial. J Orthop Trauma. 2016 ;30(7):370–5.
- Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016 ;30(7):345–52.
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