Episode 9: June Orthopaedic & Trauma Round up plus the Complications of Distal humeral #s

Listen to Sarah Gill discuss the June issue of Bone & Joint 360, with a deeper insight into the paper 'Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis'.

Paper discussed:
Yetter TR, Weatherby PJ, Somerson JS. Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2021 Mar 10:S1058-2746(21)00157-9. doi: 10.1016/j.jse.2021.02.017. Epub ahead of print. PMID: 33711499.

Transcript

[00:00:00] From the team at Bone & Joint 360 welcome to this month's podcast. We hope that these monthly podcasts are a good augment to your BJ360 reading, providing quick summaries to wet your appetite and keeping you up-to-date with the current literature. 

In this month's episode, we'll be looking at the June BJ360 issue, and I'll be summarizing my highlights from the hip and pelvis, wrist and hand, trauma and children's sections and discussing in more detail my featured article, which comes from the journal of shoulder and elbow arthroplasty, titled complications of distal humeral fracture fixation. 

But I'll start this month's episode by highlighting the June feature article and a collaborative effort from the teams in Oxford and Adelaide. Pierce Page discusses the almost philosophical question of when is a new implant not a new implant. The feature article, the first point it makes is that new trauma devices don't undergo the same process for testing that arthroplasty devices would let alone those that we might see with new medicines coming to the market. [00:01:00] And we're very familiar with the use of registry data and Odette ratings in relation to arthroplasty and the getting it right first time project called for rationalization of large implant inventories. 

But whilst comparison of outcomes by implant is commonplace in elective practice the same isn't true in trauma. In trauma the pre-market testing is usually internal, it's in-house testing by the manufacturer and the piece makes the point that a lot has to be taken on faith in relation to generalisability and real life performance.

The article makes the point that in some ways it seems impractical or even unnecessary to retest devices that have been in common use for decades. But at what point is a device different enough from its predecessors to require testing? Well, according to the European medical device regulations of 2017, new implants must be supported by clinical evidence, but it leaves it open to the manufacturer to decide [00:02:00] what that evidence should look like.

The team concludes that innovation and patient safety can only be united within an orthopaedic culture of self-regulation. They call for well-designed trials and published transparent results relating to new implants with migration towards subsequently proven devices. We've seen it work in arthroplasty and trauma should be no different.

 Moving on to the paper I'm offering up for a focal discussion this month. It's complications of intraarticular distal, humeral fracture, fixation, a systematic review and meta analysis. And the team presenting this from Texas in the US and the authors are Thomas Yetter, Paul Wetherbee and Jeremy Somerson. The article is published in the Journal of Shoulder and Elbow surgery, and it's available online at the moment ahead of print.

My attention was particularly pulled by this paper because it really made me think of the complex interarticular fractures we see in elderly patients that come through the units and the [00:03:00] treatment conundrum that exists between dual-plating, which isn't an insignificant procedure and total elbow arthroplasty. I wondered if this paper had anything to offer in relation to decision-making around these cases. 

They also noted that potential complications include mechanical failure, neuropathy, heterotopic ossification, stiffness, osteoarthritis, non-union or malunion and infection, and they sought to quantify these in order to help guide decision-making.

The authors performed a systematic review using the PubMed Embase and Cochrane library databases. And they used terms relating to both the fracture morphology, and also those relating to distal humeral fracture, fixation surgery. They excluded any level five evidence, any papers that were non-English language, anything that was meeting abstracts or studies involving the paediatric population or those that didn't clearly report outcomes of surgery. And by doing so they [00:04:00] identified 83 studies with about 2,300 elbow fixations with about a 50/50 split in terms of male, female population and a mean age of about 50.

So that's the sort of population that we're really looking at here.

In terms of the type of fractures that were discussed and presented the majority over 80% were complete articular fractures, with the articular surface, completely separated from the diaphysis with intraarticular extension. And this is the description of an AO type C fracture and the remainder, so just under 20% incomplete intraarticular fractures with some diaphyseal articular continuity so-called AO type B, and it's in fact a comparison of the type B's versus C's that is the first part of their analysis. And overall, the complication rate was similar for both groups, but the types of complication were different.

 So the type B fractures have higher rates of [00:05:00] osteoarthritis, implant discomfort, stiffness significantly 13% versus 6.5 in the type C fractures AVN and reoperation, which was mainly released related to stiffness. But the type C  fractures had higher rates of implant failure, which is about 5% and neuropathy at about 10%.

Moving on from what we might be able to predict about outcome in relation to fracture morphology they then looked at the use of electron osteotomy, which appeared to be associated with an increased risk of developing osteoarthritis  implant removal surgery or non-union. There's no explicit mention of whether there is allowance for the type of fracture in this analysis.

When examining plate construct, perpendicular constructs were actually twice as common as parallel plating, but they also had a six versus 1% increased rates of revision orif or conversion to total elbow. However, despite that increased [00:06:00] risk  of refixation or conversion to an arthroplasty parallel plating had a higher complication profile overall at 54% versus 45%. This higher complication profile included a 24% risk of reoperation, a 13% risk of ulnar neuropathy and notably a wound dehiscence rates of 5% with the parallel plating versus 0.1% in perpendicular plating and hardware failure of 13% versus 1%. So real significant differences seen there between the plating constructs.

  One of the strengths of this paper is table two in the results section, which illustrates very nicely at a quick glance, the complication profiles associated with intraarticular distal humeral fracture, fixation. And I think for me, this is really going to shape conversations with patients preoperatively, both in terms of the consenting process and their understanding of the behaviour of these [00:07:00] types of fracture and recovery and rehabilitation.

Notably there is a 50% risk of some sort of complication such as the ones we talked about at the beginning of the session. There's a 20% risk of reoperation. There's an 8% risk of stiffness, and I think that really means stiffness that's clinically significant as in probably restricting their functional range of movement type of stiffness, not mild stiffness that patients would otherwise cope well with. There's also an 8% risk of osteoarthritis and a 10% risk of neuropathy, which mainly relates to ulnar neuropathy, but not exclusively. And there's a 12% risk of having an issue with the implant, such as the plates breaking, there being prominence or discomfort from that. 

So that has really helped me add some quantification of these risks for patients that I can inform that informs that discussion. But what about in relation to my original question, which is that, can this paper [00:08:00] help me with my conundrum over to fix or to replace? And, you know, I would note that fixation is associated with 50% risk of complications, but I don't know if that's any worse than it would be with a total elbow arthroplasty. And from this paper, I can see that only 3.5% of fixations were either revised or converted to total elbows.

  So I think in relation to that question that I have what I really need is further information and particularly maybe some stratification, I'd like to see some risk factors teased out for those that did need to go on to be revised to a total elbow before I can say that this has helped me make decisions in relation to that.

 What the authors have concluded in relation to that question is that total elbow arthoplasty should be considered where we can't achieve a stable fixation construct using a plate . 

I'll now move on to presenting my [00:09:00] highlights from the various subspecialty roundup sections. And of course these are just highlights of highlights, essentially. So I do hope that you check out the rest of the article summaries in this month's edition. 

Starting with the hip and pelvis, the first paper is from the Clinical Orthopedic Related Research Journal. It considers a very familiar well-covered topic, which is sagittal plane acetabular component alignment in total hip arthroplasties, but it takes this on from a slightly  different angle, if you pardon the pun. And the team from Zionist in the Netherlands have examined interpatient variability in sagittal pelvic alignment, which of course will affect the functional position of the acetabular component.

Essentially the authors are proposing that the sagittal orientation of the cup must be decided in the context of wider factors, such as the degree of sagittal tilt to the pelvis [00:10:00] while standing, rather than just the position of the native cup on the table at the time of implantation.

The authors have quite impressively integrated their findings into a model. And this is available at www.3d-hip.com. And this would allow surgeons to trial various implantation orientations prior to a tricky case.

 The second paper in the hip and pelvis section is published in the BJJ and it comes from Stanford, California. Now, before you fast forward, when you hear the topic, the effective team composition on theatre efficiency and turnover, I'd like to defend my choosing of this paper. That is I think this paper has got a clear message, which is highly relevant to our everyday practice because unless everyone else's hospital is completely different to mine we spend a huge amount of time worrying and whining about how much better our theatre turnover could be. 

This time is an expensive commodity and the team at Stanford looked at a few [00:11:00] factors relating to data efficiency and hip and knee arthroplasty lists. The surgeon was always the same and other relevant factors like pathology, patient BMI and ASA were all controlled.

And the main finding was that changes to staff during the list, including anaesthetist, scrub and circulating nurses was associated with decreased efficiency. However, the presence of surgeon preferred staff did not increase efficiency. So the very practical take home message here is very clear, prioritize team continuity over your favorite staff to maximize efficiency of your theatre lists.

 Moving now to the wrist and hand section. There were a couple of papers, which I think can be combined to offer an update on the topic of distal radius fracture management in the over 65s. No one can ever talk about this subject without mentioning draft but whilst we know that that pragmatic study has helped shape our overall practice, [00:12:00] it's not sufficient to advise us in relation to specific fractures or individual patients. So tackling this topic with a team from Oslo, with a leader, author, Hatland, and that was published in the BJJ and the crossfire study group from Sydney publishing their work in Jama. 

Both studies compared cast mobilization to volar plating via randomized design and crucially to the message there was a difference in pathology between the two papers with the team from Oslo, including the majority of AO type C more cominuted fractures. As well as some extra articular fractures and only those that had failed a closed reduction under local anaesthetic, which was their first line treatment. However, the fractures included in the Sydney paper were predominantly type A extra articulate, simple fractures. 

In both studies fractures are included if the initial displacement was greater than 10 degrees of dorsal angulation, greater than three [00:13:00] millimeters of radial shortening, or more than two millimeters of an articular step . 

The arguments are similar across the two studies, helping combine the the message with patient-related wrist evaluation and dash scores three, six and 12 months post-treatment. In a nutshell the team from Oslow reported that dash scores at 12 months weren't significantly different in either group. 

However patient-related wrist evaluation scores were actually better in the surgical group, for all points that is at three, six and 12 months. Comparing this to the crossfire group findings, well that study result found no difference in either score at three or 12 months, but I'll highlight again that the latter study, which failed to show a significant difference including a majority of extra-articular fractures.

 So once we await the draft two study results, could these papers influence your practice? For me, I think they're [00:14:00] actually very helpful. And in patients over 65, if there was some evidence or there is some evidence here I reckon , that those with the greater baseline function really might benefit from Optim intervention, particularly in the more complex intraarticular fractures.

  Now looking at the Spine Roundup section I think this paper from Boston looking at their efficacy of telephone appointments is really worth the read. Published in the Spine journal it might escape the general reader but it's a neat and alamode paper that I think is potentially relevant to other areas of orthopaedics.

The authors have capitalized on the opportunity afforded by the change to appointments during the COVID pandemic with the wider adoption of telemedicine. And they've asked the question, Are telemedicine appointments a viable alternative to face-to-face? 

So the team at Boston retrospectively reviewed their telemedicine clinic appointments during the first five months of the pandemic, focusing on whether surgical plans [00:15:00] change when these patients were seen in person.

I think due to the numbers, we should really consider this a pilot study. But the team have reported the only two of the 33 patients seen in that initial period actually had a plan change when they were seen in person. And these changes were minor to the specifics of surgery. Namely, these two patients had their fusion extended by a single level. There weren't major changes to the management plan. 

So I think this study reports on something that we all know that as well as a challenge, the pandemic brought opportunity for innovation. And I look forward to more papers elucidating on advances in practice, including telemedicine, which if safe and effective could be a great thing for patient-centered practice.

  Our review now takes us to the Trauma section Roundup. And I think there were several interesting articles featured in this month's issue, pleading ones looking at patellar fracture plating and proximal humeral nonunion. But there were a couple in particular that I think [00:16:00] were worthy of highlighting. And the first is a study published in the JOT by a multicentre group of US authors. And I think they've identified a clinical issue that due to low numbers was always going to require a collaborative paper. And that topic is bilateral femoral fracturesand whether a stage or simultaneous fixation is the correct approach.

Having a patient in our unit recently with this injury and subsequently postoperative respiratory issues I think my eye was always going to be drawn to this one. And an update to the body of evidence on this topic is very welcome. The people sets out the issue that mortality associated with these injuries is somewhere between 6% and 32% based on the current body of literature. Somewhere between something that's really not insignificant at 6% and actually very high at 32%. 

And whilst we know the early appropriate care in the trauma patients saves lives what about the physiological insults of bilateral femoral [00:17:00] instrumentation with increased embolize and risk of RDS in this particular injury?

The study includes 10 level one trauma centres. A total of 246 patients with 188 of those undergoing a single stage  i.e. both femurs at the same time, fixation and 58 a two-stage fixation plan. Between those two arms age, sex , injuries, severity score AIS and GCs were all similar and here's the headline results: ARDS was significantly lower in the single-stage group at 6% compared to the two-stage group of 14%. However, although the study wasn't powered for this and therefore the result was not statistically significant there was an increased hospital mortality rate with the single-stage group of 2% versus [00:18:00] zero in the two-stage group.

So this is a really well done multicentre paper and overall it supports single-stage fixation of bilateral femoral fractures, but future needs to focus on the persisting question regarding mortality and the identifiable risk factors of this so that we can safely stratify patient care. 

The second paper I wanted to highlight in the Trauma section is also featured in our global Roundup with the team hailing from Athens and publishing in the BJJ on the topic of tranexamic acid in neck of femur fracture care.

So some of you may be using TXA routinely in your neck of femur fracture patients. As the majority would do with arthroplasty. But it's less well studied in this group and the team present their randomized control trial with the endpoints of total blood loss and postoperative transfusion, randomizing neck of femur fracture patients to either [00:19:00] the intervention arm, where they were given 50 milligrams per kilogram, dose of IV TXA. Or the control arm where they were given an IV placebo just prior to surgical incision.  

If you're wondering how much that is, I'd highlight that for a 70 kilogram patient, 15 milligrams per kilogram works out to about one gram. But for the slim elderly patients, it would be considerably less than that.

The TXA group had sufficiently lower blood loss at around 300 mils less on average and a 22% lower risk of transfusion than the placebo group. And there were no differences in relation to adverse events. So this level one evidence provides a really good reason to review unit protocols around the perioperative neck of femur fracture care and consider the routine use of TXA.

And finally I'll conclude our Roundup by highlighting what I think is a neat paper looking at how to identify concomitant [00:20:00] osteomyelitis in patients presenting with septic arthritis. This paper is featured in our Children's Roundup and it comes from the team in Los Angeles, published in the Journal of Paediatric Orthopedics. Now I'll give you some more details, but all you really need to remember here is the title of the paper Pain for greater than four days is highly predictive of concomitant osteomyelitis in children with septic arthritis. 

The paper makes the point that as such arthritis is considered an emergency diagnosis is usually based on history, clinical exam and quick, readily available tests, such as inflammatory markers and ultrasound. And therefore MRI is not routinely used for the diagnosis and can common and osteomyelitis associated with a poor outcome might not be diagnosed until later on. This retrospective review of 12 years of data at a tertiary centre identified 71 patients presenting with septic arthritis [00:21:00] at a mean age of six and with a mean follow-up of 14 months.

So the first thing I'd highlight here is that what the y report is that 61% of these patients presenting with septic arthritis had concomitant osteomyelitis. White cell count, ESR and CRP at time of presentation were not predictive of osteomyelitis. However, pain of greater than four days duration on history taking was in fact 96% of patients with a greater than four day history of pain had osteomyelitis compared to only 43% who presented with a shorter history of pain.

So what this paper suggests is that patients presenting with more than four days history of pain would particularly benefit from early MRI in their treatment.

  Having concluded our Roundup all that's left to say is a big thank you to the BJ360 editorial [00:22:00] team for the huge amount of work that goes into producing each issue of the journal . From myself, Sarah Gill at the Queen Elizabeth Hospital in Glasgow and the wider BJ360 team thank you for joining us on this month's podcast.

Remember to follow @BoneJoint360 on Twitter for more highlights from the latest literature. And I look forward to hosting you again for next month's episode.