Fractures of the femoral head are uncommon. Typically associated with hip dislocations, they are found in association with high-energy trauma. They occur more commonly in men than women. Because of their relatively rare occurrence, large series with validated outcomes have not been reported. As noted by Marecek et al. in the November 2015 issue of JBJS Reviews, the goals of treatment are to achieve early and safe reduction and fixation and, in doing so, avoid complications, including osteonecrosis and heterotopic ossification.
To accomplish these goals, it is important to identify any associated life-threatening injuries and to achieve prompt reduction. A distinction is made between infrafoveal and suprafoveal fractures and the presence of associated femoral neck or acetabular fractures. Operative treatment is usually accomplished through the direct anterior or surgical hip dislocation approach, depending on the associated injury patterns. The use of mini-fragment lag screw fixation is generally preferred.
The initial treatment of femoral head fractures follows advanced trauma life support (ATLS) protocols. If hip dislocation is present, urgent reduction is performed in conjunction with skeletal relaxation to decrease the risk of osteonecrosis of the hip. Nonoperative treatment is reserved for patients with infrafoveal fractures with a concentric hip joint and no intra-articular debris and patients in whom operative intervention carries a morbid risk of complications. The timing of intervention for femoral head fractures remains controversial, and at least one randomized controlled trial demonstrated significantly worse outcomes for patients who had closed manipulative reduction and delayed open reduction and internal fixation compared with patients who received immediate operative reduction and fixation.
In summary, femoral head fractures are uncommon but severe. After prompt reduction of hip dislocations, a thorough evaluation is required to detect all associated injuries and to formulate an appropriate operative plan. Treatment should be directed toward achieving a stable, concentrically reduced hip with anatomic reduction of the fracture or excision of comminution and removal of articular debris. Arthroplasty should be reserved for patients who are older, those who have degenerative changes of the hip, and those who have complex injuries, the treatment of which would be more detrimental or risky than immediate arthroplasty.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
In my 20-plus years serving as a deputy editor and editor of JBJS, I have never seen the kind of media interest in research published in The Journal that the Harper et al. study on distal radius fractures in older men has received.
This well-done retrospective evaluation of 95 males and 344 females who were treated for a distal radius fracture at a single institution has been discussed in multiple forums and media outlets, including the national newswire services, scientific and clinical blog sites, and health reports on local and national TV newscasts.
One conclusion from the Harper et al. analysis was that males older than 50 who had a distal radius fracture are receiving far worse follow-up care compared to females with the same characteristics in terms of bone-mineral density testing and subsequent pharmacologic treatment to prevent future fractures. For example, an older male with a fragility-caused distal radius fracture is nearly 10 times less likely to undergo bone-density testing than a woman with the same fracture. What is so newsworthy about this finding as to prompt headlines such as “Gender Bias in Osteoporosis Screening”?
My hypothesis is that orthopaedic research has focused too much on procedural-based interventions. When research such as the Harper et al. study extends beyond developing new therapies to matters of population health and application of evidence-based therapies, the public pays especially close attention. Previous OrthoBuzz posts by my JBJS predecessor Vern Tolo, MD and JBJS Reviews Editor-in-Chief Tom Einhorn, MD have called on clinicians to take a more aggressive approach toward primary and secondary prevention of fragility fractures. JBJS commentator Douglas Dirschl, MD says that the gender disparity revealed by Harper et al. “should shock the medical community into improved performance.”
Orthopaedic surgeons are increasingly working in teams consisting of family physicians with additional musculoskeletal training, radiologists, anesthesiologists, nurses, PTs, OTs, and athletic trainers. As our field expands its scope to “musculoskeletal health, prevention, and treatment” and away from exclusively invasive interventions, let’s continue to invite the public along. Based on the media coverage of the Harper et al. study, the public appears to be a willing partner in our attempts to reduce the risk of fragility fractures.
Do you think including preventive and population-health perspectives is the right direction for our field? Send us a comment of support or a dissenting view by clicking on the “Leave a Comment” button in the box to the left.
Marc Swiontkowski, MD
It would be an understatement to suggest that the practice of medicine has changed during the past ten years. Indeed, every physician can think of a number of things that have impacted his or her practice. However, among the positive changes that have affected how we treat patients, evidence-based medicine ranks high on the list.
Evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patient values.” Those who support evidence-based medicine note that it will prevent the bias that exists among health-care professionals who frequently base clinical decisions on custom and practice. Hence, the growth of evidence-based medicine along with the desire among clinicians to reduce variations in health-care delivery has had an important and positive impact on health-care practice and policy. Simply stated, the principles of evidence-based medicine serve as a means of decreasing variation in health-care delivery and improving patient outcomes.
The history of evidence-based medicine is interesting and is well covered in the article by David Jevsevar in the September 2014 issue of JBJS Reviews. Concepts and terms are defined, and the findings of research on health-care disparity are discussed. Clearly, the randomized controlled trial (RCT) has become the so-called gold standard in research methodology because of its ability to minimize confounding between patient groups. However, Dr. Jevsevar notes that there are concerns regarding the use of RCTs in the practice of medicine, including their expense as well as the time required for patient recruitment, data analysis, and study completion. As a result of these costs and challenges, most RCTs are now funded by industry, raising concerns about the potential external sources of bias.
This article also touches on other important concepts related to evidence-based medicine in clinical practice policy, such as the propagation and control of conflicts of interest, shared decision-making between physician and patient, and the development of best-practice applications to address the individual needs of and risks to each patient. Finally, it is apparent that the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010 introduces important and vast changes in access to the U.S. health-care system. Designed to address the unsustainable growth in federal spending and the depletion of the Medicare trust fund that is predicted to occur by 2026, this legislation represents an attempt to “bend the cost curve” by showing the increase in annual health-care expenditures. It further makes the point that the absence of an essentially controlled U.S. health-care system creates a potentially large research laboratory promoting study opportunities to investigate the delivery of high-quality, evidence-based care. Thus, the opportunity for orthopaedic surgeons to become advocates for their patients, to take a leading role in shaping the future of evidence-based medicine, and to do so in a way that generates costs that our nation can afford presents a real opportunity to positively shape the future of orthopaedic practice.
Thomas A. Einhorn, MD, Editor, JBJS Reviews
The treatment of periprosthetic infection remains one of the most difficult and challenging problems in orthopaedic surgery. Conventional approaches such as the use of tissue and/or fluid cultures to identify and treat organisms are not nearly as successful as they need to be in order to address these conditions. The limitations of treatment, including the inaccessibility of microorganisms at the time of irrigation and debridement, the development of resistant strains of microorganisms, and the elaboration by microorganisms of protective biofilms, have led to unsuccessful outcomes in a large number of cases.
In this issue of JBJS Reviews, Chen and Parvizi provide an update on some of the new methods that may possibly advance this field. Molecular methods such as polymerase chain reaction to amplify bacteria can improve the likelihood of identifying the pathogen in a patient with a periprosthetic joint infection. Synovial markers such as C-reactive protein, leukocyte esterase, α-defensin, human β-defensin-2 (HBD-2) and HBD-3, and cathelicidin LL-37 are known to be elevated in patients with periprosthetic joint infection and may be used as markers for diagnosing infection at the time of operative management. Serum markers such as interleukin-4 (IL-4) and IL-6, and others such as soluble intracellular adhesion molecule-1 (sICAM-1) and procalcitonin (PCT), have been shown to be elevated in patients with periprosthetic joint infection.
Molecular detection methods probably have received the most attention and interest as an advancement that may improve our ability to diagnose periprosthetic infections. The limitations of these methods, however, include their high sensitivity and an increased rate of false-positive results. Methods to reduce the number of false-positive results are currently in development and include, among other things, the measurement of 16S ribosomal RNA in the belief that targeting RNA will result in amplification of only the genetic material of live bacteria. In addition, use of the mecA gene for identifying methicillin-resistant Staphylococcus aureus (MRSA) can reduce this rate.
Although this article does not provide definitive new approaches to the problem, the review of recent advances with the development of promising biomarkers and molecular techniques provides optimism that this field is evolving in a positive way.
According to the orthopaedic surgeon edition of Kantar Media’s Website Usage & Qualitative Evaluation study, JBJS.org ranks hands down as the #1 orthopaedic site that surgeons visit most often and spend the most time on. The Kantar study evaluates the opinions of orthopaedic surgeons on 29 professional websites, including 8 orthopaedic sites. Not only does JBJS.org rank number 1 among the other 7 orthopaedic sites in frequency of visits (4.7 times/month), the website ranks first among all 28 sites evaluated in terms of time per session (20.31 minutes). Additionally, JBJS.org ranks #1 in delivering quality clinical content and keeping surgeons informed of the latest practices and procedures. JBJS ties for first place in the category of information on drugs, devices, or professional services. Also noteworthy is the fact that JBJS Reviews, a new online review journal from JBJS launched in November 2013, has already taken over third place in time spent and number of site visits.
JBJS Webinar Series
JBJS has held multiple live webinar events on a wide variety of topics, and we are pleased to announce the expansion of the JBJS Webinar Series in 2014. Each webinar has proven to be a successful tool in educating, informing and engaging orthopaedic surgeons around the world. In 2014, JBJS is continuing this educational program through a new series of interactive online events.
Our webinars bring together groups of authors to present recently published scientific research and data, and they include commentary from guest experts. Live Q&A sessions follow the author and commentator presentations to provide the audience with the opportunity to further explore the concepts and data presented. Webinars continue to be available on-demand for several months after the event.
AVAILABLE ON-DEMAND (Previously Recorded Events)
Total Knee Arthroplasty Critical Decision Making: Socioeconomic and Clinical Considerations (June 10, 2014) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Thomas S. Thornhill, MD
Commentators: Daniel J. Berry, MD and Kevin Garvey, MD
Preventing Arthroplasty-Associated Venous Thromboembolism (VTE) (May 12, 2014) – Moderated by Thomas A. Einhorn, MD
Panelists/Authors: Clifford W. Colwell Jr, MD and John T. Schousboe, MD
Commentators: Vincent Pellegrini Jr, MD and Jay Lieberman, MD
Anterior Cruciate Ligament (ACL) Reconstruction (March 5, 2014) – Moderated by Mark Miller, MD
Panelists/Authors: Freddie Fu, MD and Christopher Kaeding, MD
Commentators: Brett Owens, MD and Darren L. Johnson, MD
Adhesive Capsulitis/Frozen Shoulder (December 2013) – Moderated by Andrew Green, MD
Presented in conjunction with the Journal of Orthopaedic & Sports Physical Therapy.
Panelists/Authors: George Murrell, MD, Martin J. Kelley, DPT, Jo Hannafin, MD, PhD, and Philip W. McClure, PT, PhD
Periprosthetic Joint Infection (October 2013) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Craig J. Della Valle, MD
Commentators: Javad Parvizi, MD, FRCS, and Geoffrey Tsaras, MD, MPH
Measuring Value in Orthopaedic Surgery (September 2013) – Moderated by James Herndon, MD
Panelist/Author: Kevin J. Bozic, MD
Commentators: David Jevsevar, MD and Jon J.P. Warner, MD
Editor, JBJS Reviews: Thomas A. Einhorn, MD
Journals provide third-party validation for research reports. If you get published in a better journal, your work will likely be perceived as having been more successful. Editors and publishers feel the same way when it comes to how our audience rates our products. So we were very pleased when a recent independent third-party study found that our new review journal, JBJS Reviews, has rapidly become the #3 online journal in orthopaedics.
JBJS Reviews was launched just over six months ago, but it is already viewed as one of the top 3 professional resources for quality content, helping run an orthopaedic practice, and keeping surgeons informed. There are many other categories, but you get the idea – JBJS Reviews is already proving its worth.
Our Editor-in-Chief for JBJS Reviews, Tom Einhorn, MD, has done a fabulous job getting this new journal off the ground, and dozens of authors have contributed excellent reviews, and more are scheduled. We’re excited about the potential here.
That being said, the Journal of Bone & Joint Surgery still ranks #1 in nearly every category, so we have a lot to build upon there, as well. And that’s how we view it – being #1 is not a destination but an expectation, as is quickly joining the top 3. We need to keep working at a high level, improving what we do, and delivering great information in all formats.
Earlier this year, the Journal introduced the Peer-Review Statement, granting readers insight into how articles are peer-reviewed. A high percentage of readers find this valuable, we’ve learned. We are also introducing an integrated tablet app for iOS and Android devices. All our journals – the Journal, JBJS Reviews, JBJS Case Connector, and JBJS Essential Surgical Techniques – will appear in the single app. Best of all, if you already use the JBJS Reviews app, your next update will give you the integrated app seamlessly.
We value our readers and know how important your work is and how valuable your time is. I hope these improvements and high-quality resources serve you well.
In last month’s Editor’s Choice, JBJS Editor in Chief Vern Tolo. MD, called for more concerted efforts among orthopaedists to link care of fragility fractures to evaluation and treatment of osteoporosis. Now, JBJS Reviews Editor in Chief Thomas Einhorn, MD, echoes Dr. Tolo’s message in reference to the May 2 JBJS Reviews article on managing patients with osteoporotic distal radial fractures:
According to Dr. Einhorn, “This must-read article provides a concise summary of how to advance the diagnosis and treatment of osteoporosis and fragility fractures. The authors explain the latest evidence about the ‘three main pillars’ of treatment of distal radial fractures in people with osteoporosis: primary prevention, acute management, and reduction of risk of future fractures. The strides made among US orthopaedists to recognize and manage osteoporosis with programs such as the American Orthopaedic Association’s ‘Own the Bone’ initiative have been commendable. However, on a global scale, our specialty is woefully behind in taking an aggressive approach toward prevention and treatment of osteoporosis.”