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 OrthoBuzz summaries of these “What’s New” articles. This month, co-author Niloofar Dehghan, MD, selected the 5 most clinically compelling findings from the >20 studies summarized in the July 1, 2020 “What’s New in Orthopaedic Trauma.”
—An international randomized controlled trial (RCT) of hip fracture patients ≥45 years of age1 compared outcomes among 1,487 who underwent an “accelerated” surgical procedure (within 6 hours of diagnosis) and 1,483 who received “standard care” (surgery within 24 hours of diagnosis). Mortality and major complication percentages were similar in both groups, but it is important to note that even the standard-care group had a relatively rapid median time-to-surgery of 24 hours.
—An RCT of nearly 1,500 patients who were ≥50 years of age and followed for 2 years2 compared total hip arthroplasty (THA) with hemiarthroplasty for the treatment of displaced femoral neck fractures. There was no between-group difference in the need for secondary surgical procedures, but hip instability or dislocation occurred in 4.7% of the THA group versus 2.4% of the hemiarthroplasty group. Functional outcomes measured with the WOMAC index were slightly better (statistically, but not clinically) in the THA group. Serious adverse events were high in both groups (41.8% in the THA group and 36.7% in the hemiarthroplasty group). Although the authors conclude that the advantages of THA may not be as compelling as has been purported, THA’s benefits may become more pronounced with follow-up >2 years.
—A preplanned secondary analysis of data from the FAITH RCT examined the effect of posterior tilt on the need for subsequent arthroplasty among older patients with a Garden I or II femoral neck fracture who were treated with either a sliding hip screw or cannulated screws. Patients with a posterior tilt of ≥20° had a significantly higher risk of subsequent arthroplasty (22.4%) compared with those with a posterior tilt of <20° (11.9%). In light of these findings, instead of internal fixation, primary arthroplasty may be an appropriate treatment for older patients who have Garden I and II femoral neck fractures with posterior tilt of >20°.
Ankle Syndesmotic Injury
—An RCT that compared ankle syndesmosis fixation using a suture button with fixation using two 3.5-mm screws3 found a higher rate of malreduction at 3 months postoperatively with screw fixation (39%) than with suture button repair (15%). With the rate of reoperation also higher in the screw group due to implant removal, these findings add to the preponderance of recent evidence that the suture button technique is preferred.
—A 460-patient RCT examining the cost-effectiveness of negative-pressure wound therapy4 for initial wound management in severe open fractures of the lower extremity found the technique to be associated with higher costs and only marginal improvement in quality-adjusted life-years for patients.
- HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet.2020 Feb 29;395(10225):698-708. Epub 2020 Feb 9.
- Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ; HEALTH Investigators. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med.2019 Dec 5;381(23):2199-208. Epub 2019 Sep 26.
- Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy AR; Canadian Orthopaedic Trauma Society. Improved reduction of the tibiofibular syndesmosis with TightRope compared with screw fixation: results of a randomized controlled study. J Orthop Trauma.2019 Nov;33(11):531-7.
- Petrou S, Parker B, Masters J, Achten J, Bruce J, Lamb SE, Parsons N, Costa ML; WOLLF Trial Collaborators. Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial. Bone Joint J.2019 Nov;101-B(11):1392-401.
For more than 40 years, orthopaedic trauma surgeons have been interested in this fairly common fracture combination, which is often seen in polytrauma patients. We have long hypothesized that much of the energy that fractures the femoral shaft is dissipated, leaving many ipsilateral neck fractures nondisplaced and difficult to recognize on plain radiographs.
But the consequences of missing a femoral neck fracture can be devastating. For example, because the neck fracture pattern is often vertical (Pauwels type III), the risk of displacing the neck fracture during intramedullary nailing is very high. Achieving reduction and fixation of a displaced neck fracture near an intramedullary nail—either intraoperatively or postoperatively—is extremely challenging.
Because of these issues, some authors recommend a thin-cut CT series to identify nondisplaced ipsilateral neck fractures preoperatively, and this protocol has been shown to significantly reduce the delay in identifying such fractures. In the February 19, 2020 issue of The Journal, Rogers et al. from UTHealth in Houston show that even with thin-cut CT, the crack can be missed. These authors added to the protocol limited-sequence MRI that identifies these fractures with very high sensitivity and takes <10 minutes to perform.
In this study, among 39 acute, high-energy femoral shaft fractures, the authors identified 4 ipsilateral neck fractures with MRI that were not seen on CT. Despite exhibiting polytrauma, 89% of all indicated patients in this study were evaluated preoperatively with the limited-sequence MRI protocol, including those in traction and those treated initially with external fixation.
The findings from this study should prompt trauma surgeons practicing in high-volume centers to develop similar MRI protocols. It may also be possible to develop such protocols in lower-volume centers, but in those settings it is especially incumbent on the surgical team to recognize that this fracture combination occurs in a fairly high percentage of cases and to carefully scrutinize plain radiographs and consider thin-cut CT scanning of the ipsilateral hip. In addition, the potential for an ipsilateral nondisplaced femoral neck fracture should trigger increased use of fluoroscopy during intramedullary nailing of shaft fractures, so that concomitant neck fractures can be recognized and stabilized with screws before they become displaced.
Marc Swiontkowski, MD
Ample research has revealed that a patient’s psychological status influences the outcomes of many medical interventions. While orthopaedists treating patients with multiple-system orthopaedic trauma might not think first of the patient’s mental health, they should definitely take it into account, according to a prognostic study by Weinberg et al. in the March 2, 2016 Journal of Bone & Joint Surgery.
The study found that depression was an independent predictor of increased complications among 130 polytrauma patients who had preexisting psychiatric disorders. The authors also found that, relative to patients managed by a general trauma surgery service, those managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized and were less likely to receive instructions for mental-health follow-up upon discharge. The findings prompt the authors to encourage “awareness of [psychiatric] comorbidities during the treatment of orthopaedic conditions, the involvement of mental health-care providers in care, and the arrangement for meaningful mental health follow-up at the time of discharge.”
In her commentary on the Weinberg et al. study, Margaret McQueen, MD not only concurs with the authors’ admonitions, but adds that “we should control for psychiatric distress in our outcome measures to define the effect of surgical treatment more accurately.”