When I was a waiter during high school and college, I quickly learned the value of connecting with my customers. If I could fulfill whatever role they were looking me to fill (i.e., being fun and interactive, serious, acting invisible, or anything in between), I would usually be rewarded with a sizable tip or a compliment. I realized that I was not there primarily to help customers make food choices, but rather to make each customer feel as though I existed only to care for them. There is a big difference between those two roles, and I found myself thinking about those experiences while reading the article by Kortlever et al. in the February 20, 2019 issue of JBJS.
The authors aimed to determine whether an association existed between a patient’s wait time and the amount of time he or she spent with a surgeon and the patient’s perception of the surgeon’s empathy. Considering the well-established connection between the perceived empathy coming from a physician and patient satisfaction, this is an important question to examine. Interestingly, Kortlever et al. found that neither time-related variable was associated with perceived physician empathy, suggesting that decreasing wait times or spending more time with individual patients may not increase their satisfaction with the visit. However, the authors did find a direct, inverse association between surgeon stress levels and patient-perceived empathy. Specifically, for every 1-point increase in a surgeon’s self-reported stress (as measured with the Perceived Stress Scale short form), there was a 0.87 decrease in perceived empathy (as measured with the Jefferson Scale of Patient’s Perceptions of Physician Empathy).
Like most humans, patients value the quality of an interaction more than its duration. Similarly, patients are more concerned with what happens during their medical appointment than with the wait time that transpires before it. It probably does not take very long for a patient to feel that you are fully engaged with his or her concerns—or not—and increasing the length of a “bad” interaction usually will not increase its quality. Patients may not always know whether your medical advice is on target, but almost all of them can tell how much you care and whether you are “present” during their appointment.
I agree with the authors’ conclusion that the present findings indicate “that the patient-physician relationship is more built on actions and communications than on time spent.” I suspect that future studies will continue to show how powerful the perceptions of caring and empathy are when it comes to patient care.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Editor’s Note: Kortlever et al. cite a 2005 Instructional Course Lecture by Tongue et al. that describes easy-to-learn skills for effective and empathic patient-centered interviews. Click here for full text of that article.
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Kelly L. VanderHave, MD, co-author of the February 20, 2019 “What’s New in Pediatric Orthopaedics,” selected the five most compelling findings from among the more than 50 noteworthy studies summarized in the article.
—A before-and-after comparison found that, after implementation of a dedicated, weekday operating room reserved for pediatric trauma, length of stay for 5 common pediatric orthopaedic fractures was reduced by >5 hours. In addition, cost was reduced by about $1,200 per patient; complication rates improved slightly; frequency of after-hours surgery decreased by 48%; and wait times for surgery were significantly reduced.
—Forty-two patients with a distal radial buckle fracture received a removable wrist brace during an initial clinic visit, along with instructions to wear it for 3 to 4 weeks. No follow-up was scheduled, but the family was contacted at 1 week and at 5 to 10 months following treatment. No complications or refractures occurred; 100% of respondents said they would select the same treatment.1
Pediatric Sports Medicine
—Among a continuous cohort of 85 patients (mean age 13.9 years) who underwent primary ACL reconstruction (77% with open physes at time of surgery) and who were followed for a minimum of 2 years, overall prevalence of a second ACL surgery was 32%, including 16 ACL graft ruptures and 11 contralateral ACL tears. A slower return to sport was found to be protective against a second ACL injury.
Infection and Scoliosis Surgery
—A preliminary study of 36 pediatric patients who underwent a total of 191 procedures for early-onset scoliosis found that the use of vancomycin powder during closure significantly decreased the rate of surgical site infection (13.8% per procedure in the control group versus 4.8% per procedure in the vancomycin group).
—A retrospective review of >1,100 clubfeet that were presumed to be idiopathic upon presentation found that the condition in 112 feet (8.9%) was later determined to be associated with neurological, syndromic, chromosomal, or spinal abnormalities—and therefore nonidiopathic.2 The nonidiopathic group was less likely to have a good result at the 2- and 5-year follow-up, and more likely to require surgery. The authors conclude, however, that surgery is avoidable for most patients with nonidiopathic clubfoot.
- Kuba MHM, Izuka BH. One brace: one visit: treatment of pediatric distal radius fractures with a removable wrist brace and no follow-up visit. J Pediatr Orthop.2018 Jul;38(6):e338-42.
- Richards BS, Faulks S. Clubfoot infants initially thought to be idiopathic, but later found not to be. How do they do with nonoperative treatment?J Pediatr Orthop. 2017 Apr 10. [Epub ahead of print].
The main advantage of joint registries is their large number of recorded procedures, ideally with very few patient “types” not represented in the database. This is the case with the Australian Orthopaedic Association National Joint Replacement Registry, which includes data on almost 100% of all joint replacements performed in Australia since 2002. In the February 20, 2019 issue of The Journal, Jorgenson et al. analyze almost 6,000 major aseptic total knee arthroplasty (TKA) revisions from a cohort of 478,000 primary TKAs registered between 1999 and 2015. This analysis provides robust benchmark data for patients and surgeons, although it comes too late for the 3% of patients who required such a revision surgery within the 15-year study period.
The authors found that fixed bearings were revised for aseptic reasons at a significantly lower rate than mobile bearings (2.7% vs 4.1%, respectively) and that patients <55 years old had an almost 8-fold higher revision rate compared to patients ≥75 years old ( 7.8% versus 1.0%, respectively). The study also found lower aseptic revision rates with minimally stabilized total knee prostheses compared to posterior-stabilized prostheses, and higher aseptic revision rates with completely cementless fixation relative to either hybrid or fully cemented fixation. These are valuable data for arthroplasty surgeons in terms of selecting implants and surgical techniques and for preoperative counseling of patients—especially younger ones. While many of these findings have been previously reported, these registry-based results add significant strength to published data.
Ideally, data such as these would be controlled for confounding variables such as surgeon experience and additional patient-specific variables such as activity demands and medical comorbidities. Still, these data provide useful prosthesis-specific factors for shared decision making with patients. We look forward to more helpful information from this and other national joint registries and encourage the continued growth of similar registries in other subspecialties.
Marc Swiontkowski, MD
The anticipation of postoperative pain associated with a large operation such as a total knee arthroplasty (TKA) scares many patients. Some worry to the point of “catastrophizing” pain prior to surgery. As orthopaedic surgeons, we try to assuage our patients’ fears through preoperative education and multimodal pain-management modalities after surgery, but there are still some patients in whom the fear of pain—and the pain itself that inevitably accompanies arthroplasty— negatively affect their outcome. Preparing such patients for surgery and helping them recover afterward despite this high anxiety are big challenges for the orthopaedic care team. Some data suggest that cognitive behavioral therapy (CBT) might help.
However, a multisite randomized trial by Riddle et al. published in the February 6, 2019 issue of JBJS did not find any differences in pain or function among patients with moderate to high preoperative pain catastrophizing scores who underwent a form of CBT focused on pain coping skills, when their outcomes were compared to those of similar patients in “usual care” or “arthritis education” arms of the study. Each group had similar WOMAC pain scores and pain catastrophizing scores to start, and all patients were found to have significant but very similar decreases in their pain scores at 2, 6, and 12 months postoperatively. Independent assessors determined that the quality of the intervention in the coping-skills and arthritis-education arms was high, suggesting that it was not poor-quality interventions that accounted for the consistent similarities among the 3 groups.
While there are many physiological and psychological factors contributing to an individual’s experience of pain, the results of this study ran surprisingly counter to prior evidence. The authors speculate that differences between the 3 groups may have been masked by the fact that all patients had such a large decrease in pain after the TKA. While that would appear to be good news, we know that there is a stubbornly large subset of patients (cited in this article as 20%) who undergo a technically and radiographically ”successful” knee arthroplasty only to have continued pain without an obvious cause. (See related OrthoBuzz Editor’s Choice post.)
These findings lead me to believe a statement that probably cannot be proven: there are some patients who will experience function-limiting pain no matter what surgery is performed, no matter which drugs are administered, and no matter what rehabilitative therapy is provided. Learning how to identify those patients and clearly communicating expectations to them pre- and postoperatively might help improve their satisfaction with their procedure.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
After some relatively poor results in the 1980s, there was a “reboot” with total ankle arthroplasty (TAA) in the late 1990s to improve outcomes so that TAA would provide a reliable treatment for patients with end-stage ankle arthritis. Advances in the understanding of the biomechanical requirements for ankle prostheses and which patients might benefit from them the most—plus the realization that TAA is a technically demanding surgical procedure that requires advanced education—have vastly improved the outcomes of these procedures. In fact, TAA has become reliable enough that we can now begin to tease out the patient variables that seem to affect outcomes.
In the February 6, 2019 issue of The Journal, Cunningham et al. use an extensive clinical TAA registry to identify patient characteristics that impact TAA outcomes. The good news is that, 30-plus years after the inauspicious outcomes of first-generation TAA, overall pain and function significantly improved among the patients in this study. However, current smoking was associated with poorer patient outcomes at the 5-year follow-up, as it seems to be with the vast majority of orthopaedic procedures. Also, at a mean 1- to 2-year follow-up, a previous surgical procedure on the ankle was associated with significantly smaller improvements in at least 1 patient-reported outcome. This makes sense because prior surgery leads to scarring and its attendant risk of infection and increased difficulty with exposure and the ideal placement of TAA components. Cunningham et al. also identified depression as being associated with worse TAA outcomes at all follow-up points, adding to our already ample body of evidence that patient psychological factors play a major role in orthopaedic surgical results.
Interestingly, these authors found that patients undergoing staged bilateral ankle arthroplasty did not do as well as those undergoing simultaneous bilateral TAAs. And somewhat surprisingly, the authors found obesity to be associated with better outcomes at the 5-year follow-up. This may be related to increased bone density and greater soft-tissue coverage, but this finding is still seemingly counterintuitive based on everything else we know about the negative associations between obesity and outcomes of other joint replacements.
As more surgeons and orthopaedic centers make use of TAA, it will be important for us to follow the lead of the total knee and total hip communities in providing large datasets to further clarify which factors—patient-related and surgical—lead to the best and worst patient outcomes. This study by Cunningham et al. provides a starting point upon which other research will hopefully build.
Marc Swiontkowski, MD
How much opioid analgesia do pediatric patients need after closed reduction and percutaneous pinning of a supracondylar humeral fracture? Not as much as they are being prescribed, suggests a study of 81 kids (mean age of 6 years) by Nelson et al. in the January 16, 2019 issue of The Journal of Bone & Joint Surgery.
All patients in the study underwent closed reduction and percutaneous pinning at a single pediatric trauma center. The authors collected opioid utilization data and pain scores (using the Wong-Baker FACES scale) for postoperative days 1 to 7, 10, 14, and 21 via a text-message system, with automated text queries sent to the phones of the parents/guardians of the patients. (Click here for another January 16, 2019 JBJS study that relied on text messaging.)
Not surprisingly, the mean postoperative pain ratings were highest on the morning of postoperative day 1, but even those were only 3.5 out of a possible 10. By postop day 3, the mean pain rating decreased to <2. As you’d expect, postoperative opioid use decreased in parallel to reported pain.
Overall, patients used only 24% of the opioids they were prescribed after surgery. (See related OrthoBuzz post about the discrepancy between opioids prescribed and their actual use by patients.) Considering that pain levels and opioid usage decreased in this patient population to clinically unimportant levels by postoperative day 3, the authors conclude that “opioid prescriptions containing only 7 doses would be sufficient for the majority of [pediatric] patients after closed reduction and percutaneous pinning without compromising analgesia.”
Now that some normative data such as these are available, Nelson et al. “encourage orthopaedic surgeons treating these common [pediatric] injuries to reflect on their opioid-prescribing practices.” They also call for prospective randomized studies into whether non-narcotic analgesia might be as effective as opioid analgesia for these patients.
After a wildly successful inaugural visit to Saudi Arabia in 2018, the 5-day Miller Review Course (MRC) for orthopaedists in training will return to Riyadh from April 22-27, 2019, at the Fairmont Hotel.
The location for this intense and comprehensive orthopaedic review course—the Saudi capital and the nation’s most populous city—caters to attendees from Asia, the Middle East, and Africa, but it is open to orthopaedists-in-training from anywhere in the world. Attendees will receive not only the finest in orthopaedic review courses, but also an eye-opening introduction to Saudi life, culture, and food.
The expert Miller faculty will cover 9 orthopaedic subspecialties, plus basic science, statistics, anatomy, and musculoskeletal rehabilitation. In line with Saudi medical training, this version of the MRC is conducted exclusively in English.
The expansion of the largest orthopaedic review course in the US to the Middle East is a unique opportunity for any orthopaedic resident/registrar to prepare for the next step in their career.
Click here to register and to preview the faculty and agenda.
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries. This month, Michael J. Taunton, MD, author of the January 16, 2019 “What’s New in Adult Reconstructive Knee Surgery,” selected the five most compelling findings from among the more than 100 noteworthy studies summarized in the article.
Cementless vs Cemented TKA Fixation
—A matched case-control study of 400 primary total knee arthroplasties (TKAs) found that cementless TKAs had a 0.5% rate of aseptic loosening over a mean follow-up of 2.5 years, while cemented TKAs had an aseptic loosening rate of 2.5%.1
TKA Component Size in Obese Patients
—Among 35 revision-TKA patients with a varus collapse of the tibia, 29 weighed >200 lbs. Fehring et al. found that patients with implants at the small end of the range of the manufacturer’s tibial size offering and with >5° of preoperative varus were at increased risk of tibial-component failure.2
—A retrospective multivariate analysis of >4,300 patients who underwent outpatient TKA and >128,900 patients who underwent inpatient TKA found that, within 1 year, those who had outpatient procedures were more likely to experience a tibial and/or femoral component revision due to a noninfectious cause, irrigation and debridement, explantation of the prosthesis, and stiffness requiring manipulation under anesthesia.
—In a randomized trial of patients undergoing TKA, one group received 15 mg/kg of systemic intravenous vancomycin, and a second group received intraosseous regional administration of 500 mg vancomycin into the tibia. Mean tissue concentrations of the antibiotic were 34.4 mg/g in the intraosseous group and 6.1 mg/g in the intravenous group, suggesting that intraosseous administration provides a significantly higher tissue concentration of that antibiotic. 3
TKA Anesthesia Protocol
—A retrospective review of 156 consecutive patients who underwent primary TKA found that procedures performed with mepivacaine spinal anesthesia led to fewer episodes of urinary catheterization and shorter mean length of stay compared with procedures performed with bupivacaine spinal anesthesia.4
- Miller AJ, Stimac JD, Smith LS, Feher AW, Yakkanti MR, Malkani AL. Results of cemented vs cementless primary total knee arthroplasty using the same implant design. J Arthroplasty.2018 Apr;33(4):1089-93. Epub 2017 Dec
- Fehring TK, Fehring KA, Anderson LA, Otero JE, Springer BD. Catastrophic varus collapse of the tibia in obese total knee arthroplasty. J Arthroplasty.2017 May;32(5):1625-9. Epub 2017 Jan 30.
- Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS Clinical Research Award: intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee arthroplasty: a randomized trial. J Arthroplasty.2018 Jul;33(7S):S13-8. Epub 2018 Mar 15.
- Mahan MC, Jildeh TR, Tenbrunsel TN, Davis JJ. Mepivacaine spinal anesthesia facilitates rapid recovery in total knee arthroplasty compared to bupivacaine. J Arthroplasty.2018 Jun;33(6):1699-704. Epub 2018 Jan 16.
Trying to educate elderly patients and their family members about how to best treat a femoral neck fracture can be difficult. These patients typically have multiple—and often severe—medical comorbidities that can make even the most “simple” surgery complex and life-threatening. Making such discussions even harder is the lack of Level-I evidence related to treating these common injuries. For severely displaced fractures, the evidence supports performing either a hemi- or total hip arthroplasty on most patients. But the data is much less clear for minimally or nondisplaced fractures.
For these reasons, I was excited to read the study by Dolatowski et al. in the January 16, 2019 issue of JBJS. The authors performed a prospective, randomized controlled trial comparing internal screw fixation to hemiarthroplasty for valgus impacted or nondisplaced femoral neck fractures in >200 patients with a mean age of 83 years. They found that patients who underwent hemiarthroplasty had a significantly faster “up-and-go” test and were significantly less likely to undergo a major reoperation than those who underwent internal fixation. However, patients in the internal-fixation group were less likely to develop pulmonary complications. There were no between-group differences in overall hip function (as evaluated with the Harris hip score) or in the 24-month mortality rate.
This study lends support to what many surgeons tell elderly patients with a nondisplaced femoral neck fracture: a hemi- (or total) arthroplasty will probably provide the lowest risk of needing a repeat operation for the injury, while placing percutaneous screws may decrease the risk of cardiopulmonary complications related to the operation. While these findings may not be surprising, this study provides important Level I data that can help us educate patients and their families so that the best treatment for each individual patient can be determined.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
The relationship between orthopaedic foot and ankle surgeons and podiatric surgeons has been checkered. Many have advocated that the orthopaedic community should isolate itself from interaction with the podiatric community. Conversely, a smaller group of orthopaedic foot and ankle surgeons have recommended sharing CME endeavors with podiatric surgeons, and combining clinical services with them. As long as individual states continue to legislate surgeon scope-of-practice matters (38 states currently allow podiatric surgeons to perform ankle surgery), it seems to me that shared learning, combined clinical services, and collaborative research make the most sense for advancing foot and ankle care for as many patients as possible. We should all be willing to work with our surgical colleagues to improve everyone’s decision making and skill.
In the January 16, 2019 issue of The Journal, Chan et al. probe an administrative database to evaluate several outcomes after total ankle arthroplasty (TAA) and ankle arthrodesis performed by both types of surgeon. Probably because many podiatrists self-limit their practices to forefoot surgery, podiatric surgeons provided the treatment for only 18% of the patients in both ankle-surgery groups. When podiatrists were the primary surgeon, the authors found increased lengths of stay for both procedures and increased hospital costs for arthrodesis patients. The authors did not investigate the reasons for these increases, but they should be investigated in the future. Chan et al. did find that, in general, podiatric surgeons operated on sicker patients and tended to work in smaller, non-teaching hospitals.
The authors also found an increasing percentage of these procedures being performed by podiatrists over the period from 2011 to 2016. This is likely related to multiple factors, including variable availability of orthopaedic foot and ankle surgeons relative to podiatric surgeons in many communities, and an increased number of podiatry training programs that specialize in hindfoot surgery.
It seems to me that data like these from Chan et al. should be shared with both communities to foster discussions regarding how to optimize length of stay, costs, and patient outcomes across the board. The goal should always be to raise every surgeon’s level of care for the benefit of all patients.
Marc Swiontkowski, MD