All you stats geeks out there will love the January 6, 2016 study in The Journal of Bone & Joint Surgery by Schilling and Bozic. We at OrthoBuzz are going to skip the gory statistical details for the most part and focus on the essential findings.
First the premise and purpose of the study: Because measuring and improving health care outcomes are nowadays top priorities, risk adjustment—methods to account for differences in patient characteristics across providers—has become a contentious issue. General risk-assessment models tend not to be well-tailored to orthopaedic procedures. So Schilling and Bozic developed a series of risk-adjustment models specific to 30-day morbidity and mortality following hip fracture repair (HFR), total hip arthroplasty (THA), and total knee arthroplasty (TKA). To develop their models, they used prospectively collected clinical data from the National Surgical Quality Improvement Program.
Here are the major findings: For THA and TKA, risk-adjustment models using age, sex, and American Society of Anesthesiologists (ASA) physical status classification were nearly as predictive as models using many additional covariates. HFR model discrimination improved with the addition of comorbidities and laboratory values. Vital signs did not improve model discrimination for any of the procedures.
The study confirms that it is possible to provide adequate risk adjustment for analyzing outcomes of these procedures using only a handful of the most predictive variables commonly available within the operative record. “More parsimonious models are a viable alternative when the adequacy of risk adjustment must be weighed against the cost and burden of large-scale data extraction from the clinical record,” the authors conclude.
In the December 2, 2015 issue of The Journal, Reindl et al. report on the results of a multicenter randomized trial comparing intramedullary (IM) fixation versus sliding hip screws for stabilization of type A2 unstable intertrochanteric fractures. This trial is yet another product of the Canadian Orthopaedic Trauma Society (COTS), which has collaborated on high-quality clinical trials for more than a decade.
There have been more than 20 RCTs comparing intramedullary fixation with sliding hip screws. Many of these trials exclusively investigated stable fracture patterns or included both stable and unstable fractures. These studies generally concluded that nails provide no clear outcome benefits, except perhaps in unstable fractures. Several meta-analyses have also been published that identified no significant difference in clinical or functional outcomes.
Up until now, there has been little dispute with the recommendation that unstable intertrochanteric fractures be fixed with intramedullary implants. While this current trial confirms radiographic advantages to IM fixation (significantly less femoral-neck shortening) after 12 months, Reindl et al. found but no significant functional advantage (in terms of Lower Extremity Measures, Functional Independence Measures, or timed up-and-go tests) with IM fixation in unstable A2 fractures. These findings add more evidence to the claim that IM implants for both stable and unstable patterns are overused in North America.
The question now becomes how many more trials do we need to further make the point? We know that powerful surgeon-behavior influences exist in academic medical centers that continue to use intramedullary implants routinely for intertrochanteric hip fractures (see the 2010 JBJS prognostic study by Forte et al.). Considering the much higher cost of intramedullary nails relative to hip screws, it is high time that these same centers teach appropriate use of IM implants for these fractures so that trainees become facile with both implant types.
Marc Swiontkowski, MD
Currently, each year more than 300,000 Americans sustain a hip fracture, and that number is expected to rise to more than 500,000 within the next 20 to 30 years. A new study– based on a literature review, analysis of Medicare claims, and input from clinical experts–finds that the average lifetime societal benefit from surgery to repair hip fractures reduced the direct medical costs of the surgery by $65,000 per patient. Collectively, that results in an estimated $16 billion lifetime societal savings. These savings include reductions in length of and intensity of postinjury care, and the amount of required long-term medical care and assistance required by surgery patients relative to those whose fractures are treated nonsurgically. The study, published in Clinical Orthopaedics and Related Research, also found that the quality-adjusted life years in people with surgically treated hip fractures increased 2.5 years for patients with intracapsular fractures and 1.9 years for those with extracapsular fractures. To view a summary of the article, read here.
A recent meta-analysis of eight randomized trials (1,408 total patients) compared aspirin to anticoagulants such as warfarin and dabigatran for preventing venous thromboembolism (VTE) after hip and knee arthroplasty and hip-fracture repair. The analysis found that the overall prophylactic power of these two medical approaches was essentially equal following major lower-extremity surgery. However, the comparison, appearing in the Journal of Hospital Medicine, found a slightly higher (but statistically nonsignificant) risk of deep vein thrombosis (DVT) with aspirin following hip-fracture repair. Conversely, the risk of bleeding after hip-fracture surgery was lower with aspirin than with anticoagulants.
For additional insight into VTE prophylaxis, view the FREE recorded JBJS webinar “Preventing Arthroplasty-Associated Venous Thromboembolism.” Register here.
A home-based exercise program modestly improved physical function in older adults who completed a standard rehabilitation program after a hip fracture, according to a recent JAMA study.
Half of nearly 200 older adults with limited function after finishing rehab were randomized to home exercises; the other half received in-home and phone-based nutrition education. The exercise group learned functional tasks (such as standing from a chair and climbing a step) during three hour-long home visits by a physical therapist, and then performed the tasks on their own three times weekly for six months. After six months, the exercise group had better scores of physical function — as measured by the Short Physical Performance Battery and Activity Measure for Post-Acute Care — than the control group.
While the clinical importance of these findings remains to be established, the results suggest that an extended period of structured at-home rehabilitation could help older patients sidestep some of the long-term functional limitations that often persist following a hip fracture.