Much has been written in recent years about the orthopaedist’s predilection for prescribing opioids, most of which has been aimed at helping us become better stewards of these medications. It is imperative that we continue learning how best to prescribe opioids to maximize their effectiveness in postoperative pain management, while minimizing their many harmful and potentially lethal effects. With some patients, finding that balance is much easier than with others. Learning to identify which patients may struggle with achieving that equilibrium is one way to address the current opioid epidemic.
In the September 18, 2019 issue of The Journal, Prentice et al. identify preoperative risk factors that are associated with prolonged opioid utilization after total hip arthroplasty (THA) by retrospectively evaluating the number of opioid prescriptions dispensed to >12,500 THA patients. Many of the findings are in line with those of previous studies looking at this question. Prentice et al. found that the following factors were associated with greater opioid use during the first postoperative year:
- Preoperative opioid use
- Female sex
- Black race
- Higher BMI
- Substance abuse
- Back pain
- Chronic pulmonary disease
For me, the most noteworthy finding was that almost 25% of all patients in the study were still using opioids 271 to 360 days after their operation. That is a much higher percentage than I would have guessed prior to reading this study. Somewhat less surprising but also concerning was the finding that 63% of these patients filled at least 1 opioid prescription in the year prior to their THA, leading the authors to suggest that orthopaedic surgeons “refrain from prescribing opioids preoperatively” or “decrease current opioid users’ preoperative doses.”
Although some readers may be suffering from “opioid fatigue” in the orthopaedic literature, I encourage our community to continue addressing our role in the current opioid crisis. While I believe that we have changed our prescribing practices since the data for this study were collected (2008 through 2011), we cannot dismiss these findings. The opioid epidemic is multifactorial and has many deep-rooted tendrils in our healthcare system. We owe it to our patients and to the public at large to be as significant a part of the solution as possible.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
The rate of adoption of knowledge gleaned from multiple well-done randomized clinical trials into medical practice is disappointingly slow. This has been well-documented in cardiovascular medicine, and the examples in orthopaedic surgery are embarrassingly similar. A corollary phenomenon exists with the slow rate of transfer of information from basic science studies to orthopaedic clinical practice.
These “disconnects” occur largely because we tend to adopt the practices of our residency faculty, often without any rational inquiry. Having been an oral examiner for the Part II ABOS Oral Boards, I frequently asked, “Why did you decide on that approach to the patient’s problem?” And I often heard in response, “That’s the way it was done in my residency.”
In the September 18, 2019 issue of The Journal, Goswami et al,. report findings from a well-designed in vitro study demonstrating that the common practice of adding the antibiotics polymyxin and bacitracin to irrigation solution to lower the risk of infection is not based on sound evidence. While adding antibiotics might make intuitive sense, according to these authors, it is “a futile exercise.”
After testing 8 different irrigation solutions for efficacy against S. aureus and E. coli and for toxicity to musculoskeletal cells, Goswami et al. concluded that “our results provide further support for the use of dilute povidone-iodine because of its bactericidal properties, relatively limited toxicity,… and modest cost.” They go on to say that their findings bring into question the widespread usage of polymyxin-bacitracin.
Certainly, we need to assemble more evidence from additional research to identify the optimal irrigation solution for orthopaedic surgery, but in the interim, we should probably stop using polymyxin-bacitracin. Doing so would have the added benefits of lowering costs and not exacerbating the serious problem of antimicrobial resistance. There are many areas of clinical practice where we have no evidence either for against a particular approach. But when we do have solid evidence, even if it’s from an in vitro study, we should work together to improve the rates of adoption into clinical practice.
Marc Swiontkowski, MD
The treatment of early-onset scoliosis with Mehta casting is a long process, but if successful, it can delay or obviate the need for surgery. In the September 4, 2019 issue of JBJS, Fedorak et al. examine outcomes among 38 patients (mean age of 24 ± 15 months at time of first casting) who were treated with Mehta casting and followed for a mean of 8 ± 2 years. The retrospective review identified differences between patients who had a Cobb angle ≤15° (improvement group) at the most recent follow-up and those who had a Cobb angle of >15° (no-improvement group).
Forty-nine percent of children had achieved and maintained scoliosis of ≤15° at the time of the most recent follow-up, and 73% were improved by at least 20°, although 3 children ended up relapsing after meeting recommended criteria for discontinuation of casting. There was no significant difference in thoracic-height gain between the groups, demonstrating that even when scoliosis was not corrected, growth was maintained during cast treatment.
Patients in the improvement group had a mean age of 18.9 ± 12 months and scoliosis of 48.2° ± 14° at the initiation of treatment. Here are 3 additional factors that were associated with a greater likelihood of scoliosis of ≤15°:
- A lower pre-treatment Cobb angle and traction Cobb angle
- A smaller rib-vertebral angle difference on first-in-cast radiograph
- A lower Cobb angle on first-in-cast radiograph
The authors note that although this study analyzed longer-term follow-up data than most other similar investigations, “treatment of early-onset scoliosis is not truly finished until skeletal maturity has been reached.”
For most patients and payers, getting out of the hospital quickly after a knee replacement is very important. For orthopaedic surgeons, excellent patient outcomes are the top priority. The latest one-hour complimentary webinar from JBJS on Tuesday, October 1, 2019 at 8:00 pm EDT will reveal clinical practices that increase the odds of achieving both of those goals.
Co-authors Nelson SooHoo, MD and Armin Arshi, MD will explore data from their JBJS study comparing complication rates after outpatient and inpatient knee-replacement, emphasizing that outpatients must receive the same attention to infection prevention, thromboprophylaxis, and rehabilitation as inpatients.
Kurt Spindler, MD and Robert Molloy, MD will then delve into their JBJS study, which suggests that hospital site, surgeon, and day of the week are more accurate predictors of length of hospital stay after knee replacement than patient age, BMI, and comorbidities.
Moderated by Daniel Berry, MD of the Mayo Clinic, the webinar will also feature expert commentaries by Joseph Moskal, MD and Ronald Delanois, MD. The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.
Seats are limited, so Register Now!
There are few things more discouraging for an orthopaedic surgeon than a late postoperative complication after what was an otherwise successful surgery. One such scenario occurs when patients who have undergone open reduction/internal fixation (ORIF) for a distal radial fracture subsequently experience a flexor pollicis longus (FPL) tendon rupture. While previous literature has suggested that plate positioning plays a role in that complication, no studies have evaluated whether newer plate designs decrease contact with the FPL tendon and therefore reduce the risk of rupture.
With that question in mind, Stepan et al. evaluated two cohorts of patients who had undergone ORIF for a distal radial fracture. In the September 4, 2019 issue of JBJS, they report on findings from 40 patients, 20 of whom received a standard distal radial volar locking plate, and 20 of whom received a plate designed with a distal cutout to afford the FPL more room to traverse.
Ultrasound analysis revealed that similar percentages of patients in each group had FPL–plate contact (65% in the FPL-plate group and 79% in the standard-plate group), and there were no differences between groups in terms of FPL tendon degeneration as seen on ultrasound. However, patients who received the FPL plate had significantly less of the tendon come in contact with the plate at 0° and 45° of wrist extension. The authors noted, however, that this difference may have been influenced by the fact that patients with the FPL-specific plate also had significantly lower volar tilt than patients with the standard locking plate. It is therefore not possible to determine whether it was the plate design or the bone position (or both) that led to these results.
It is also noteworthy that the two senior authors of this study work as consultants for the company that manufactures the plates that were evaluated. It is also important to note that because all the patients in this study were asymptomatic, further research is needed to determine the clinical importance of reduced tendon–plate contact area. We should temper our excitement about specially designed volar plates until we have more clinical data supporting their success in avoiding the problem for which they were designed.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Medical education is a constant need, but how it’s delivered is always changing. When my grandfather was a surgeon, medical trainees brought their dusty textbooks and print journals to “fireside chats” at an attending’s home. Today, we have online journals, tablets and smartphones, podcasts, and “virtual” discussions on social media platforms. Although the technologies evolve, the need to discuss present and past literature remains constant.
These discussions often taken place nowadays through journal clubs. Medical residents across the continent routinely get together in formal or informal settings to discuss journal articles, not only to acquire the knowledge contained in the articles themselves, but also to learn how to properly read, critique, and digest the information.
JBJS provides medical education across multiple platforms, several of which I participate in. I strongly encourage residency programs to submit an application for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program before the deadline of September 30, 2019. The grant allows medical educators to support their journal clubs in many ways:
- Investigating new and innovative alternatives to the traditional journal club.
- Bringing an author to your institution to discuss his or her articles.
- Hosting a virtual journal club with multiple authors via teleconference or social media.
- Purchasing food and refreshments within the “old school” method of a fireside chat at an attending’s home.
No matter the platform or methodology, journal clubs are a vital part of orthopaedic education, not only for interpreting literature, but also for incorporating knowledge into future clinical practice and for the joy and excitement of lifelong learning.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
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, Mark T. Dahl, MD, co-author of the August 21, 2019 “What’s New in Limb Lengthening and Deformity Correction,” selected the five most clinically compelling findings from among the 40 noteworthy studies summarized in the article.
–Authors of a retrospective study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia found a 69% union rate at maturity. They did not identify specific factors influencing rates of union or refracture, however.1
–The models created with this technology can help surgeons preoperatively assess specific anatomical geometries. Corona et al.2 used 3-D-printed titanium truss cages, along with the Masquelet technique, to treat massive infected posttraumatic defects.
Growth Prediction in Limb Lengthening
–A comparative evaluation of the predictive accuracy of 4 methods to correctly time epiphysiodesis in 77 patients found the multiplier method to be the least accurate. In a separate study of 863 epiphysiodeses, authors reported a 7% complication rate.3 The most common complication was incomplete arrest that resulted in angular deformities; half of those cases required reoperation.
Congenital Limb Deficiencies
–Over 16 years, Finnish children born with lower-limb deficiencies had 6 times the number of hospital admissions and 10 times the number of days in hospital per child, compared with children born without a limb deficiency.4
- Shah H, Joseph B, Nair BVS, Kotian DB, Choi IH, Richards BS, Johnston C, Madhuri V, Dobbs MB, Dahl M. What factors influence union and refracture of congenital pseudarthrosis of the tibia? A multicenter long-term study. J Pediatr Orthop. 2018 Jul;38(6):e332-7.
- Corona PS, Vicente M, Tetsworth K, Glatt V. Preliminary results using patient-specific 3D printed models to improve preoperative planning for correction of post-traumatic tibial deformities with circular frames. Injury. 2018 Sep;49(Suppl 2):S51-9.
- Makarov MR, Dunn SH, Singer DE, Rathjen KE, Ramo BA, Chukwunyerenwa CK, Birch JG. Complications associated with epiphysiodesis for management of leg length discrepancy. J Pediatr Orthop. 2018 Aug;38(7):370-4.
- Syvänen J, Helenius I, Koskimies-Virta E, Ritvanen A, Hurme S, Nietosvaara Y. Hospital admissions and surgical treatment of children with lower-limb deficiency in Finland. Scand J Surg. 2018 Nov 19:1457496918812233. [Epub ahead of print]
Early or late dislocation after total hip arthroplasty (THA) is a dreaded complication, and performing a THA to treat a hip fracture is known to increase the risk of postoperative prosthetic joint dislocation. Large-diameter femoral heads, like those used in metal-on-metal implants, offered the prospect of decreased risk of dislocation. Unfortunately, their promise of improved stability was subsequently offset by serious issues with wear. Orthopaedics is notable for technology that promised to solve one problem but led to another, and some wonder whether the increasing popularity of THA using dual-mobility cups to reduce dislocation risk might lead to another example of this paradoxical problem.
However, in the July 17, 2019 issue of The Journal, Jobory et al. published a population-based prospective cohort analysis based on data from the Nordic Arthroplasty Register Association. That study demonstrated a reduced revision risk with dual-mobility acetabular components when THA was performed to treat hip fracture in elderly patients. The authors propensity-score matched 4,520 hip fractures treated with dual-mobility THA to 4,520 hip fractures treated with conventional THA. The study included surgeries from 2001 to 2014, and the median follow-up was 2.4 years for all patients.
Dual-mobility constructs had a lower overall risk of any-component revision (hazard ratio of 0.75), which persisted after authors adjusted for surgical approach (hazard ratio of 0.73). Additionally, the dual-mobility construct had a lower risk of revision due to dislocation (hazard ratio of 0.45), but there was no difference in risk of deep infection between the cohorts. There was no significant difference in risk of any-component revision for aseptic loosening (hazard ratio of 0.544, p=0.052) until the authors adjusted for approach, which resulted in a decreased risk of any-component revision for aseptic loosening (hazard ratio of 0.500, p=0.030). When the authors compared revision of the acetabular component only, they found a reduced risk of revision for any cause as well as revision for dislocation in the dual-mobility cohort using both unadjusted data and data adjusted for surgical approach. Mortality was higher in the dual-mobility group compared with the conventional-component group (hazard ratio of 1.5).
Overall, this study gives us more information regarding the short-term revision risks of an implant design that is gaining popularity in the US. Although dual-mobility constructs seem to be associated with a decreased risk of revision for dislocation in a population of older adults with hip fracture, this data tells us little about this design and technology when used in younger, more active patients, who are at higher risk of polyethylene wear.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
It is no secret that patients with Medicaid (both adults and children) have difficulty making appointments for both elective and trauma-related orthopaedic care. They also travel further for care compared to privately insured patients. Conversely, Medicaid reimbursement rates for orthopaedic surgeries are substantially lower than those from Medicare and commercial insurers. Patients with Medicaid also tend to be more socially complex and have higher no-show rates for clinic appointments and surgery.
Consequently, as recently as 2011, only 40% of US orthopaedic surgeons were accepting new patients with Medicaid. This “bottleneck” effect may only get worse as reimbursement plans shift towards “pay-for-performance” and value-based payment, prompting surgeons and hospitals to become increasingly concerned about optimizing patient selection.
In a 2012 JBJS study, my colleague Ryan Calfee and co-authors demonstrated that patients with Medicaid were traveling to our institution (Washington University/Barnes Jewish Hospital in St. Louis) not only for complex cases, but also for simple and moderate-complexity hand surgery issues. These patients were bypassing hand surgeons closer to home partly because the local hand surgeons did not accept Medicaid.
With those findings in mind, we decided to more closely examine Medicaid care delivery in our region. Ideally, the insurance mix of the area surrounding a hospital should match the payer mix of the hospital. Most of us who currently work or have trained in large academic centers know that this is often not the case. Anecdotally, there are hospitals in every region that “cherry pick” the best-insured patients and transfer out the financially less desirable cases to a nearby teaching hospital. In our paper, published in the August 21, 2019 issue of JBJS, the concept of “Medicaid share ratio” is intended to reflect whether the hospital payer mix matches the insurance mix of the community. A value of 1 indicates a perfect balance.
We examined the Medicaid share ratios of the 22 hospitals in our region to see if the hospitals were “pulling their weight.” The Medicaid share ratios for elective orthopaedic care such as total joint arthroplasty ranged from 0.05 to 4.73, demonstrating massive imbalances on both ends of the spectrum. We also found very high variability in the delivery of elective orthopaedic care (coefficient of variation = 93, where values >60 are considered “very high”) and moderate variability in trauma care (coefficient of variation = 34).
Our findings were sobering, but not unexpected. The fact that some hospitals bear the brunt of care for the underinsured and uninsured is not new, and the federal government currently includes Disproportionate Share Hospital (DSH) payments to offset these losses. However, DSH payments are scheduled to decrease substantially in coming years as part of the original intent of the Affordable Care Act. If the continuing (and possibly worsening) burden of undercompensated care becomes financially suffocating to teaching and safety-net hospitals, they may seek to curb those losses in ways that could further limit access to underinsured patients and/or drive costs up for patients with other types of insurance.
At the surgeon level, we should address surgeon hesitation to accept Medicaid patients through engagement with specialty societies and policy reform. Our research team is currently working to learn more about what surgeons and patients think are potential solutions for these disparities in our region. As surgeons and researchers, we must work toward a more complete understanding of what drives these disparities in orthopaedic care. Otherwise, it will be impossible to figure out how to fix them.
Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.