OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in Arthritis Care & Research, the following commentary comes from Jeffrey B. Stambough, MD.
As orthopaedic surgeons, we share a collective objective to help patients improve function while minimizing pain. When patients come to our office for a new clinical visit for knee osteoarthritis (OA), we spend time getting to know them and gathering information about their activities, limitations, and functional goals. We balance this patient-reported information with discrete data points, such as weight, range-of-motion restrictions, and radiographic disease classification. Based on the symptom duration and other factors, most patients are not candidates for a knee replacement at this first visit. However, despite the publication of clinical practice guidelines for the nonoperative management of knee OA in 2008, with an update in 2013, significant variation exists in how orthopaedists treat these patients.
This guideline–practice disconnect is emphasized in findings from a recent study in Arthritis Care & Research that examined nonoperative knee OA management practices during clinic visits between 2007 and 2015. The authors found that the overall prescription of NSAID and opioid medications increased 2- and 3-fold, respectively, over that time, while recommendations for lifestyle interventions, self-directed activity, and physical therapy decreased by about 50%.
To me, the most troubling finding from this study is the sharp increase in narcotic prescriptions, because recent evidence demonstrates that narcotics do not effectively treat arthritis pain. Moreover, for patients who go on to arthroplasty, recent studies have found that preoperative opioid use portends worse postsurgical outcomes in terms of higher revision rates, worse function scores, and decreased knee motion.
The findings from this study also speak to a larger societal issue for doctors and patients alike: the desire for a “quick fix.” Despite the time pressure from increasing EHR documentation burdens, dwindling reimbursements, or lack of local resources, we owe it to our patients to counsel them on lifestyle modifications and self-management strategies to help them stay mobile, lose weight (if necessary), and take charge of their joint health. As orthopaedic surgeons, we must continue to strive to de-emphasize opioid pain medication when treating knee OA patients and support them in a holistic manner to ensure their overall health and the function and longevity of their native knee joint.
Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.
Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
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.
Only about 10% to 15% of patients with low back pain who are referred to a spine surgeon actually require a surgical procedure. And because low back pain is such a common presenting complaint, many such patients often wait a long time for a surgery consult. In the December 19, 2018 issue of JBJS, Coyle et al. demonstrate that a simple, 3-item patient-administered questionnaire can identify those better suited for nonoperative management—and thus increase the likelihood that surgical candidates are seen by spine surgeons in an acceptable time frame.
All 227 of the Canadian patients enrolled in this randomized controlled trial received the questionnaire, which elicited information to distinguish between patients with leg-dominant radicular pain and those with back-dominant pain. Evidence-based guidelines recommend nonoperative management for most back-dominant pain, while patients with leg-dominant pain are more likely to need surgery. Researchers randomized 116 patients into an intervention group; these patients were triaged by a spine surgeon and then had their triage status upgraded if responses to the questionnaire indicated leg-dominant symptoms. The 111 patients in the control group were triaged only by a spine surgeon.
After triage, 33 of the 227 patients (15%) were recommended for a surgical procedure—16 from the intervention group and 17 from the control group. Of the 16 surgical candidates identified from the intervention group, 9 (56%) were re-prioritized on the basis of questionnaire results.
The median wait time for a consultation among the 16 surgical candidates in the intervention group was 2.5 months, compared with 4.5 months for the 17 surgical candidates in the control group. A significantly greater percentage of patients in the intervention group than in the control group were seen for a consult with a spine surgeon within the “acceptable” time frame of 3 months. Another benefit of the questionnaire approach evaluated in this study is that it helps identify nonsurgical candidates early, so they can be directed toward more appropriate treatment (such as physical therapy) rather than delaying treatment while waiting for a consult with a spine surgeon.
Although this study was conducted in the setting of the “nationalized” Canadian health care system, wait times to see orthopaedic surgeons and neurosurgeons are also long for many patients in many regions of the US. This questionnaire enhancement to triage could therefore be viable throughout North America, and perhaps beyond.
Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.
In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).
Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.
Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media