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.
In the June 7, 2017 issue of The Journal of Bone & Joint Surgery, Pincus et al. report on a careful analysis comparing outcomes from hip fracture surgery occurring “after hours” (defined by the authors as weekday evenings between 5 PM and 12 AM) with surgeries occurring during “normal hours” (weekdays from 7 AM to 5 PM). In the busy Ontario trauma center where this study was performed, it is common for patients with blunt trauma to take precedence over seniors who are relatively stable but in need of hip fracture care.
Pincus et al. found that adverse outcomes, in terms of surgical and medical complications, were similar whether the hip surgery occurred during normal hours or after hours. Interestingly, there was a higher rate of inpatient complications in the normal-hours group, and fewer patients in the after-hours group were discharged to a rehab after surgery than in the normal-hours group.
It has been my impression that highly skilled professional surgeons and their teams are going to put forward their best efforts for all patients—no matter what time of day or night they operate. Concentration, focus, and high standards can generally overcome fatigue. However, the Pincus et al. study should not be viewed as justification for hospital decision makers to forget their commitment to optimize management of all resources, including surgical teams. After-hours care should never become “routine,” and there should be continuous attention on developing alternative solutions, such as moving elective surgery to other facilities or true shift scheduling that provides all members of the team with occasional daytime hours off for rest and management of personal lives.
The authors note that in their Canadian jurisdiction, there are hospital and surgeon-reimbursement incentives that may work to promote after-hours surgery, but the long-term focus must always put patient outcomes first. And we must always remember that good patient outcomes rely on maintaining surgical teams who are experienced and not burnt out.
Marc Swiontkowski, MD
From the perspective of a geriatric patient with a hip fracture, having a preoperative echocardiogram may not seem like a big deal, especially since it’s a noninvasive test. However, as Adair et al. reveal in an April 19, 2017 JBJS study, following clinical guidelines established by the American College of Cardiology (ACC) and the American Heart Association (AHA) could have prevented “cardiac echoes” from being done in 34% of 100 elderly hip fracture patients without missing any disease. Such unnecessary testing not only adds cost to the health care system, but can also delay surgical treatment for an operation that evidence suggests is best performed within 24 to 48 hours.
A single reviewer blinded to the later results of the tests assessed whether the ACC/AHA guidelines were followed in each case of an ordered echo; when ≥1 of the criteria were met, the echo was considered ordered in accordance with the guidelines. The rate of adherence to the guidelines was 66% over the 3.5-year study period. No important heart disease was found in any of the 34 patients who underwent an echocardiogram that had not been indicated by the guideline criteria, and 14 of the 66 patients (21%) for whom an echo was indicated by the criteria were found to have heart conditions serious enough to modify anesthesia or medical management.
The most common documented reasons for ordering an echo outside the guideline criteria were dementia that prevented evaluation of preoperative cardiac condition and generic “evaluation of cardiac function,” even though those patients had no history, physical exam findings, or work-ups that suggested heart disease.
Adair et al. conclude that these findings “suggest that integration of [clinical practice guidelines] into a perioperative protocol has the potential to improve the efficiency of preoperative evaluation, reduce resource utilization, and reduce the time to surgery without sacrificing patient safety.”
In the past several years, the orthopaedic community has become highly engaged in improving the follow-up management of patients presenting with fragility fractures. We have realized that orthopaedic surgeons are central to the ongoing health and welfare of these patients and that the episode of care surrounding a fragility fracture represents a unique opportunity to get patients’ attention. Using programs such as the AOA’s “Own the Bone” registry, increasing numbers of orthopaedic practices and care centers are leading efforts to deliver evidenced-based care to fragility-fracture patients.
In the November 16, 2016 edition of The Journal, Aspenberg et al. carefully examine the impact of the anabolic agent teriparatide versus the bisphosphonate risedronate on the 26-week outcomes of more than 170 randomized patients (mean age 77 ±8 years) who were treated surgically for a low-trauma hip fracture. This investigation is timely and appropriate because our systems of care are evolving so that increasing numbers of patients are receiving pharmacologic intervention for low bone density both before and after a fragility fracture.
The secondary outcomes of the timed up and go (TUG) test and post-TUG test pain were better in the teriparatide group, but there were no differences in radiographic fracture healing or patient-reported health status.
Although this study was designed primarily to measure the effects of the two drugs on spinal bone mineral density at 78 weeks, these secondary-outcome findings confirm the value of initiating pharmacologic intervention early on after a fragility fracture, whether it’s a bisphosphonate or anabolic agent. The orthopaedic community needs to continue leading multipronged efforts to deal with the public health issues of osteoporosis and fragility fractures.
Click here for additional OrthoBuzz posts related to osteoporosis and fragility fractures.
Marc Swiontkowski, MD
BMJ recently published two studies of interest to orthopaedists:
- After analyzing data from more than 200 cardiovascular, orthopaedic, and neurologic devices approved in both the US and European Union (EU), Hwang et al. found that those approved in the EU first were nearly three times as likely to trigger a safety alert or experience a recall than those first approved in the US. Finding further that trial results were published for fewer than half of approved devices considered “major innovations,” the authors call for “greater regulatory transparency” so physicians and patients can make better-informed decisions. Interestingly, Figure 2 in this study showed that the FDA approval time for orthopaedic devices was faster than ortho-device approval times in the EU. However, a JBJS study earlier this year found that devices approved via the FDA’s “quick” 510(k) process were 11.5 times more likely to be recalled than those cleared through the longer and more stringent FDA pathway.
- In the second BMJ article, a registry-based case-control study, Abrahamsen et al. found that the long-term use of the bisphosphonate alendronate does not increase the risk for atypical femoral fractures (either subtrochanteric or femoral shaft), while protecting against hip fractures. After applying some sophisticated statistical analyses, the authors estimated that 38 patients with ≥5 years of alendronate adherence would need to be treated for an additional 5 years to prevent one hip fracture, while 1449 similar patients would need to be treated to cause an atypical femoral fracture. Click here for more OrthoBuzz coverage of the relationship between bisphosphonates and atypical femoral fractures.
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
Austin Moore’s article “The Self-Locking Metal Hip Prosthesis” was published in The Journal of Bone & Joint Surgery in 1957. Dr. Moore had a lifelong professional interest in hip-fracture surgery and was well aware of the problems associated with reduction and fixation of displaced femoral neck fractures. He had previously designed an internal-fixation device for the management of these injuries and had recognized that perfect reduction, accurate placement of the hip nail, and 100% compliance with non-weight bearing were prerequisites for a satisfactory outcome. For patients in whom those criteria could not be met or those in whom reduction and fixation had failed, an alternate method of managing these fractures was required.
Fourteen years prior to the publication of this landmark article, Dr. Moore had published a case report in The Journal (July 1943) in which he documented the use of a metal prosthesis to replace the proximal end of the femur for a patient with an aggressive giant cell tumour. Some years later the patient succumbed from other causes and the femur was retrieved at autopsy. The specimens demonstrated satisfactory osseointegration of this implant in the proximal femur and encouraged Dr. Moore to experiment with a number of models of proximal femoral implants. This progression of implant design and usage is carefully outlined in this classic paper, which is amply illustrated with radiographs and autopsy specimens of the evolving prosthesis that eventually became known as the Austin Moore hip prosthesis.
This paper is notable for a number of reasons. First, Dr. Moore was able to demonstrate satisfactory fixation using an intramedullary stemmed implant—a significant departure from the early efforts of the Judet brothers and others, who used a small stem in the residual femoral neck in patients being treated for hip arthritis. Secondly, the author developed a specific surgical approach allowing for the insertion of these slightly curved stems into the femur—an approach that is still used today in a number of surgical hip procedures.
Third, Dr. Moore demonstrated the usefulness of proximal femoral replacement in acute displaced femoral neck fractures, avascular necrosis following femoral neck fracture, and non-unions of the femoral neck. He further expanded the use of this implant in the treatment of hip arthritis and documents a number of such cases in this article.
Throughout the article, Dr. Moore emphasizes the importance of meticulous surgical technique, the use of bone ingrowth fixation, careful sizing of the femoral head to the native acetabulum, and the importance of conscientious post-operative care. Finally, he recognized the importance of routine follow-up of endoprostheses and insisted on a yearly visit to ensure appropriate integration of the prosthesis.
In summary, with this article Dr. Moore started a trend of endoprosthetic treatment for displaced femoral neck fractures that is now the standard of care throughout much of the world. During the development of this technique, he demonstrated the importance of bone ingrowth as a method of stabilizing the prosthesis, the importance of good surgical technique, and the value of long-term follow-up in managing patients with hip prostheses. The fact that the implant he designed and reported on 60 years ago is still in widespread use is a reflection of his vision.
James P. Waddell MD, FRCSC
JBJS Deputy Editor
The orthopaedic community has been aware of racial disparities in care delivery for two decades. The phenomenon has been most clearly elucidated in joint replacement surgery, but in the May 18, 2016 edition of The Journal, Dy et al. confirm that the issue is also at play in hip fracture care.
The authors analyzed the prospectively collected records of nearly 200,000 New York State residents who underwent hip fracture surgery between 1998 and 2010. After multivariable adjustment for factors such as patient characteristics and hospital/surgeon volume, Dy et al. found that black patients were at significantly greater risk for delayed surgery, a reoperation, readmission, and 1-year in-hospital mortality than white patients. The authors also found that patients covered by Medicaid (a marker for low socioeconomic status) were at increased risk for delayed hip-fracture surgery.
It is time for the orthopaedic community to develop an organized strategy to deal with this important social issue. Recruitment into the ranks of orthopaedists of underrepresented minorities, enhanced cultural-sensitivity training, and culturally relevant patient and family educational materials may begin to address the situation. Perhaps the AAOS, the AOA, and the J. Robert Gladden Orthopaedic Society could convene a meeting to develop such a strategic plan? I am confident we can begin to reduce racial and socioeconomic disparities if we put our collective minds to it.
Marc Swiontkowski, MD