Every month, JBJS publishes 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, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 25 noteworthy studies summarized in the July 3, 2019 “What’s New in Orthopaedic Trauma” article.
Proximal Humeral Fractures in the Elderly
–A recent meta-analysis1 analyzing data from >1,700 patients older than 65 who experienced a proximal humeral fracture found no difference in Constant-Murley scores at 1 year between those treated operatively (most with ORIF using a locking plate) and those treated nonoperatively. There was also no between-group difference with respect to reoperation rates among a subgroup of patients from the 7 randomized trials examined in the meta-analysis.
–A study using MRI to evaluate soft-tissue injuries in 17 cases of “simple elbow dislocation”2 found that the most common soft-tissue injury was a complete tear of the anterior capsule (71% of cases), followed by complete medial collateral ligament (MCL) tears (59%) and lateral collateral ligament tears (53%). These findings challenge previous theories positing that elbow instability starts laterally, with the MCL being the last structure to be injured.
Pertrochanteric Hip Fractures
–A trial randomized 220 patients with a pertrochanteric fracture to receive either a short or long cephalomedullary nail.3 There were no significant differences between the 2 groups at 3 months postsurgery in terms of Harris hip and SF-36 scores, but patients treated with the short nail had significantly shorter operative times, less blood loss, and shorter hospital stays. The incidence of peri-implant fractures between the 2 devices was similar.
Ankle Syndesmosis Injuries
–A randomized trial involving 97 patients with syndesmosis injuries compared functional and radiographic outcomes between those treated with a single syndesmotic screw and those treated with suture-button fixation. At 6 months, 1 year, and 2 years after surgery, patients in the suture-button group had better AOFAS scores than those in the screw group. CT scans at 2 years revealed a significantly higher tibiofibular distance among the screw group, an increase in malreduction that was noted only after screw removal. That finding could argue against early routine syndesmotic screw removal.
–A randomized trial among 470 patients4 facing elective removal of hardware used to treat a below-the-knee fracture compared the effect of intravenous cefazolin versus saline solution in preventing surgical site infections (SSIs). The SSI rate was surprisingly high in both groups (13.2% in the cefazolin group and 14.9% in the saline-solution group), with no statistically significant between-group differences. The authors recommend caution in interpreting these results, noting that there may have been SSI-diagnosis errors and that local factors not applicable to other settings or regions may have contributed to the high SSI rates.
- Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH,Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg.2018 Aug;27(8):1526-34. Epub 2018 May 4.
- Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. J Shoulder Elbow Surg.2019 Feb;28(2):341-8. Epub 2018 Nov 8.
- Shannon S, Yuan B, Cross W, Barlow J, Torchia M, Sems A. Short versus long cephalomedullary nailing of pertrochanteric hip fractures: a randomized prospective study. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2018 Oct 17-20; Orlando, FL. Paper no. 68.
- Backes M, Dingemans SA, Dijkgraaf MGW, van den Berg HR, van Dijkman B, Hoogendoorn JM, Joosse P, Ritchie ED,Roerdink WH, Schots JPM, Sosef NL, Spijkerman IJB, Twigt BA, van der Veen AH, van Veen RN, Vermeulen J, Vos DI,Winkelhagen J, Goslings JC, Schepers T; WIFI Collaboration Group. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. 2017 Dec 26;318(24):2438-45.
Among the elderly, low-energy hip fractures are common injuries that almost all orthopaedic surgeons encounter. While operative management is typically the standard of care, there are some patients for whom nonoperative treatment is most aligned with their goals of care, usually because of chronic disease, fragility, and/or high risk of perioperative mortality.
When counseling elderly patients and family members about the risks and benefits of surgical management for a hip fracture, we have abundant data. We can estimate the length of rehabilitation, discuss the likelihood of regaining independence with ambulation, and quote the 30-day, 1-year, and 5-year mortality statistics. But what about the risks and benefits of nonoperative care? How long do these patients live? How many are alive 1 year after the fracture?
Chlebeck and colleagues attempt to answer those questions with a retrospective cohort study of 77 hip fracture patients who were treated nonoperatively and a matched cohort of 154 operatively treated hip fracture patients. Nonoperative management was chosen only after a palliative-care consult was obtained and after a thorough multidisciplinary discussion of treatment goals with the patient and family. Patients who elected nonoperative care were treated with early limited weight bearing and a focus on maximizing comfort. Researchers established a comparative operative cohort through 2:1 matched pairing, controlling for age, sex, fracture type, Charlson Comorbidity Index, preinjury living situation, preinjury ambulatory status, and presence of dementia and cardiac arrhythmia.
As one might expect, there was significantly lower mortality in the operative group. The in-hospital, 30-day, and 1-year mortality for nonoperatively treated patients was 28.6%, 63.6%, and 84.4% respectively. The mortality rates seen in the operative cohort were 3.9%, 11.0%, and 36.4% respectively. A Kaplan-Meier survival analysis revealed the median life expectancy in the nonoperative cohort to be 14 days, versus 839 days in the operative group (p <0.0001). Interestingly, the researchers found no difference in hospital length of stay between the two groups (5.4 vs. 7.7 days; p=0.10).
These results provide useful references for orthopedic surgeons to use when counseling hip fracture patients and their families. Surgical intervention remains the standard of care in most instances, and this study suggests that operative care offers a significant mortality benefit over nonoperative care even in relatively unhealthy patients, like those selected for the matched operative cohort.
This study also gives us data to help guide the expectations of patients who decide surgery is not in line with their wishes. Half of the patients who elected nonoperative care in this study died within 14 days of admission, and only 15.6% were still alive at 1 year. Additionally, choosing nonoperative care does not lengthen hospitalization, suggesting that these patients can be quickly transferred to a more comfortable setting.
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.
The practice of using a geriatrician- or a hospitalist-based co-management team to care for elderly patients who are admitted to the hospital for treatment of fragility fractures or other orthopaedic procedures is now more than a decade old. These services have grown in popularity because patients are living longer with comorbidities and becoming more complex to manage medically, and because shift-based hospitalist practices have become more common. These coordinated partnerships help the hospitalist- or geriatrician-led medical team optimize the patient’s care medically, while allowing the orthopaedic surgeon to focus on the patient’s musculoskeletal condition. The consensus I have heard is that patients are better off with these co-management systems, but hard evidence has been sparse.
In the April 17, 2019 issue of The Journal, Blood et al. report on the use of the Institute for Healthcare Improvement (IHI) Global Trigger Tool to assess the adverse-event impact of a Geriatric Hip Fracture Program (GHFP). In a bivariate analysis of pre- and post-GHFP data, the authors document a decrease in the rate of adverse events and shorter lengths of stay among elderly hip-fracture patients after GHFP implementation. However, multivariable analysis confirmed only a trend toward decreasing adverse-event rates after the implementation of the program. This study also seems to confirm what many of us already know empirically—that hip-fracture patients with severe medical comorbidities (i.e., a high Charlson Comorbidity Index) are at increased risk of adverse events no matter what system of care they receive.
Still, what most orthopaedic surgeons have felt was a “no-brainer,” coordinated approach to optimizing patient care and decreasing adverse events now has more evidence of effectiveness. Because such programs decrease both adverse events and length of stay among elderly patients hospitalized for a hip fracture, orthopaedic surgeons everywhere should advocate for increased geriatrician training to support this movement. Furthermore, these findings should encourage further research into additional patient-centric medical care strategies that could improve outcomes for these patients.
Marc Swiontkowski, MD
Most health researchers attribute the well-defined racial disparities seen in outcomes for both acute and chronic illnesses to unequal access to health care, particularly preventive care. There are currently between 30 million and 40 million uninsured patients in the US who do not have access to routine preventive care and receive the majority of their health care through hospital emergency rooms. This seems to be related to the prevailing opinion in our country that access to primary care physicians and routine preventive measures is not a basic right.
Emergency care, however, is more or less available to everyone, and that would theoretically reduce or eliminate the racial disparities in outcomes for emergent conditions such as hip fractures. Yet, in 2016, JBJS published research indicating that disparities in care and outcome occur in the management of hip fracture, with black patients found to be at greater risk for delayed surgery, reoperation, readmission, and 1-year mortality than white patients. That begs the question whether there are inherent racial differences beyond the health-care delivery system that might partly account for these disparate outcomes.
In the July 5, 2018 issue of The Journal, Okike et al. try to answer that question. The authors used data from Kaiser Permanente, a large health system with a modestly diverse population that has equal access to care that is known for its adherence to standardized protocols. Okike et al. analyzed the outcomes of nearly 18,000 hip fracture patients according to race (black, white, Hispanic, and Asian). In this uniformly insured population with few or no barriers to access, Okike et al. found that the outcomes for patients, regardless of race, were similar. These findings strongly suggest that when patients are given equal access to health care that is delivered according to standardized protocols, the racial disparities found in previous studies of outcomes of emergent conditions may disappear.
Okike et al. are quick to emphasize that their findings are not an indication that “efforts to combat disparities are no longer required.” I would argue that this study further supports the need to address the issue of access to care on a policy level if we are going to make progress toward achieving racial equality in medical and orthopaedic outcomes. Much of the access-to-care progress we made between 2008 and 2016 is evaporating; I look forward to the day when we can redirect the national focus on this issue at the highest policy-making levels.
Marc Swiontkowski, MD
Few 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
It 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.
In 1922, Kellogg Speed, MD said in his American College of Surgeons address, “We enter the world under the brim of the pelvis and exit through the neck of the femur.” Since then, it has been repeatedly shown that femoral-neck and intertrochanteric hip fractures are associated with a high mortality rate during the first year following fracture. Now, in the era of widespread hip arthroplasty—and with the consequently increasing rates of periprosthetic fractures near the hip joint—it is relevant to ask whether periprosthetic fractures are associated with an increased risk of mortality similar to that seen after native hip fractures. In the April 4, 2018 issue of The Journal, Boylan et al. use the New York Statewide Planning and Research Cooperative System database to address that question.
The authors reviewed 8 years of native and periprosthetic hip fracture data to determine whether the 1-month, 6-month, and 12-month mortality risk between the two patient cohorts was similar. They found that the 1-month mortality risk in the two groups was similar (3.2% for periprosthetic fractures and 4.6% for native fractures). However, there were significant between-group differences in mortality risk at the 6-month (3.8% for periprosthetic vs 6.5% for native) and 12-month (9.7% vs 15.9%) time points.
This makes clinical sense because, in general, patients experiencing a native hip fracture have lower activity levels and general fitness and higher levels of comorbidity than patients who have received a total hip arthroplasty. Extensive research has resulted in protocols for lowering the risk of mortality associated with native hip fractures, such as surgery within 24 to 48 hours, optimizing medical management through geriatric consultation, and safer and more effective rehabilitation strategies. We need similar research to develop effective perioperative protocols for patients experiencing a periprosthetic fracture, as this study showed that 1 out of 10 of these patients does not survive the first year after sustaining such an injury. I also agree with the authors’ call for more research to identify patients with periprosthetic fractures who are “at risk of worse outcomes at the time of initial presentation to the hospital.”
Marc Swiontkowski, MD
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 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:
Autologous Chondrocyte Implantation Compared with Microfracture in the Knee: A Randomized Trial
G Knutsen, L Engebretsen. T C Ludvigsen, J O Drogset, T Grøntvedt, E Solheim, T Strand, S Roberts, V Isaksen, and O Johansen: JBJS, 2004 March; 86 (3): 455
In the first published randomized trial to compare these 2 methods for treating full-thickness cartilage defects, both procedures demonstrated similar clinical results at 2 years of follow-up. The authors also performed arthroscopic and histologic evaluations at 2 years and again found no significant differences between the groups. Since 2004, however, longer-term follow-ups have suggested that autologous chondrocyte implantation is more durable than microfracture (see Clinical Summary on Knee Cartilage Injuries).
The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip
M R Baumgaertner, S L Curtin, D M Lindskog, and J M Keggi: JBJS, 1995 July; 77 (7): 1058
So-called “cutout” of the lag screw in sliding hip screw fixation of peritrochanteric hip fractures was a recognized cause of failure long before this landmark JBJS study was published in 1995. Twenty-three years later, when value consciousness has repopularized this reliable fixation method (especially in stable fracture patterns), the tip-apex distance as a strong predictor of cutout remains an important surgical consideration.
The bundled-payment model has found some early success within the field of orthopaedic surgery, most notably in joint replacement (see related OrthoBuzz post), However, more robust risk-adjustment methods are needed, especially in terms of patient factors. That is the message delivered by Cairns et al. in their retrospective analysis of Medicare data from 2008 to 2012 published in the February 21, 2018 edition of JBJS. The authors make a compelling case for improved risk stratification of hip- and femur-fracture patients to ensure that all patient populations have and retain access to appropriate care.
The authors analyzed reimbursements for the surgical hospitalization and 90 days of post-discharge care among nearly 28,000 patients who met inclusion criteria for the Surgical Hip and Femur Fracture Treatment (SHFFT) model proposed by the Centers for Medicare and Medicaid Services (CMS). Their findings highlighted various inconsistencies that could have unintended consequences if not accounted for in the bundled-payment model. For example, reimbursements were $1000 to $2000 lower for patients in their 80s, who tend to have more comorbidities that require more care, than for younger patients. CMS proposed using Diagnosis Related Groups (DRGs) and geographic location to adjust for risk in its SHFFT bundled-payment model, but Cairns et al. identify several other factors (such as patient age and gender, ASA and Charlson Comorbidity Index scores, and procedure type) that could provide a more realistic stratification of risk.
The article clearly articulates how risk adjustments that don’t include more specific patient factors could lead to a multitude of unintended consequences for patients, providers, and the entire healthcare system. These findings could remain relevant now that CMS has announced an “advanced” voluntary bundled-payment model after the Trump administration cancelled SHFFT in late 2017.
Whatever bundled-payment model takes hold, the totality of the orthopaedic literature strongly suggests that the best outcomes are derived from making specific treatment plans for each patient based on the individual characteristics of his or her case. It seems reasonable that the best bundled-payment plans would do the same.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
People 100 years old and older—centenarians—make up only 0.02% of the current US population. Nevertheless, the number of centenarians is expected to increase five-fold by 2060. That is in part what prompted Manoli III et al. to analyze a large New York State database to determine whether patients ≥100 years old who sustained a hip fracture fared worse in the hospital than younger hip-fracture patients. The study appears in the July 5, 2017 issue of The Journal of Bone & Joint Surgery.
Only 0.7% of the more than 168,000 patients ≥65 years old included in the analysis sustained a hip fracture when they were ≥100 years old. Somewhat surprisingly, centenarians incurred costs and had lengths of stay that were similar to those of the younger patients. However, despite those similarities, centenarians had a significantly higher in-hospital mortality rate than the younger patients. Male sex and an increasing number of comorbidities were found to predict in-hospital mortality for centenarians with hip fractures.
Manoli III et al. also found that, relative to other age groups, centenarians were managed nonoperatively at a slightly higher frequency when treated for extracapsular hip fractures. For intracapsular fractures, an increasing proportion of patients >80 years were managed with hemiarthroplasty and nonoperative treatment. Finally, among centenarians, time to surgery did not affect short-term mortality rates, suggesting a potential benefit to preoperative optimization.