Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, find out how to interpret low bone mineral density in premenopausal women. Discover whether ultrasonography is better than conventional radiography at detecting cartilage calcification in patients with calcium pyrophosphate deposition. Learn why runners are not at increased risk for osteoarthritis of the knee, which factors best diagnose traumatic anterior shoulder stability, and more.

In this month's Practice Management, discover an easy, inexpensive way to boost morale and improve your office culture.

In Article of the Month, please enjoy free access to an article from the current issue of the Journal of Pediatric Orthopaedics.

Have a comment or suggestion? Contact me at editor@c-orthopaedicpractice.com.

Sincerely,
Nanci Kulig
Editor, COP eNews
editor@c-orthopaedicpractice.com

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Managing low bone mineral density in premenopausal women

Interpretation of bone mineral density (BMD) test results in premenopausal women is challenging. The relationship between BMD and fracture risk is not the same as it is in postmenopausal women.
     In most cases, z scores, rather than t scores, should define "low" BMD in premenopausal women. A finding of low BMD in a premenopausal woman should prompt a thorough evaluation for secondary causes of bone loss. If the patient has a secondary cause, treatment should focus on that condition. If a secondary cause cannot be diagnosed or managed, treatment with a bone-active agent to prevent bone loss should be considered.
     In women without fractures and no known secondary cause, low BMD is associated with microarchitectural defects similar to those in younger women with fractures. However, no longitudinal data are available to allow use of BMD to predict fracture risk. BMD typically is stable in women with isolated low BMD, and drug therapy rarely is necessary. Assessing markers of bone turnover and performing follow-up BMD testing can help to identify women with ongoing bone loss, which may indicate a higher risk for fracture and a need for drug treatment.

Source: Cohen A, Shane E. Evaluation and management of the premenopausal woman with low BMD. Curr Osteoporos Rep. 2013 Oct 4. [Epub ahead of print]

Predicting implant failure with roentgen stereophotogrammetric analysis

Roentgen stereophotogrammetric analysis (RSA) is an established method to measure implant migration, and it can help predict early implant failure. Model-based RSA eliminates the need to attach tantalum markers to the prosthesis, a procedure that has prevented wider use of RSA. So far, computer-aided design (CAD) and reverse-engineered, model-based RSA have not been validated for use in hip resurfacing arthroplasty (HRA).
     Results from a new study involving use of RSA to predict implant failure after HRA indicate that marker-based RSA is significantly more precise than model-based RSA. However, problems with occluded markers exclude many patients from this method of RSA. Model-based RSA does not have this limitation.
     Investigators conducted a phantom study to determine the precision of marker-based and CAD and reverse-engineered model-based RSA on an HRA implant. In a clinical study, 19 patients were followed with stereoradiographs for 5 years after surgery. Double-examination migration results were analyzed to determine the clinical precision of marker-based and CAD model-based RSA. At 5-year follow-up, investigators compared results of the total translation and the total rotation for marker- and CAD model-based RSA.
     The phantom study demonstrated that marker-based RSA was more precise than model-based RSA with regard to total translation and total rotation. Double examination in 8 patients demonstrated that marker-based RSA was better at evaluating total translation, but there was no difference between marker- and CAD model-based RSA analysis in predicting total rotation.

Source: Lorenzen ND, Stilling M, Jakobsen SS, et al. Marker-based or model-based RSA for evaluation of hip resurfacing arthroplasty? A clinical validation and 5-year follow-up. Arch Orthop Trauma Surg. 2013 Oct 8. [Epub ahead of print]

Use of ultrasound to detect cartilage calcification in knees

Ultrasound is better than conventional radiography at detecting cartilage calcification at knee level in patients with calcium pyrophosphate deposition (CPPD), according to new study findings. In the study, ultrasonography detected hyaline cartilage spots in at least one knee in 60% of patients, compared with 46% of patients who were assessed by use of conventional radiography. Meniscal fibrocartilage calcifications were detected by ultrasonography in at least one knee in 91% of patients, compared with 84% by use of radiography.
     Investigators assessed 314 knees in 157 patients: 74 with CPPD disease, 19 with rheumatoid arthritis, 17 with spondyloarthritis, 32 with osteoarthritis, and 15 with gout. All patients underwent a clinical examination, synovial fluid analysis, and radiographic assessment of the knee. Two operators assessed 20 patients to calculate interobserver reliability.
     Based on their findings, investigators concluded that ultrasonography has high sensitivity, specificity, and accuracy in detecting articular cartilage calcification. Both ? values and overall agreement percentages demonstrated moderate to excellent agreement.

Source: Gutierrez M, Di Geso L, Salaffi F, et al. Ultrasound detection of cartilage calcification at knee level in calcium pyrophosphate deposition disease. Arthritis Care Res (Hoboken). 2013 Oct 7. [Epub ahead of print]

Discovering which tissues contribute to low-back pain

Injection of hypertonic saline into deep tissues of the back (subcutis, muscle, or the surrounding fascia) can induce acute low-back pain (LBP). A recent study analyzed the role of the thoracolumbar fascia as a potential source of LBP.
     In separate sessions, 12 healthy patients received ultrasound-guided bolus injections of isotonic saline (0.9%) or hypertonic saline (5.8%) into the erector spinae muscle, the thoracolumbar fascia (posterior layer), and the overlying subcutis. Patients were asked to rate intensity, duration, quality, and spatial extent of pain. Investigators measured pressure pain thresholds pre- and postinjection.
     Injections of hypertonic saline into the fascia caused a significantly larger area under the curve of pain intensity over time compared with injections into subcutis or muscle, primarily based on longer pain duration and, to a lesser extent, higher peak pain ratings.
     Pressure hyperalgesia was induced by injection of hypertonic saline only into muscle, not fascia or subcutis. Pain radiation and level of pain evoked by injection into fascia exceeded pain evoked by injection into muscle or subcutis significantly. Patient descriptions of pain after fascia injection (burning, throbbing, and stinging) suggested innervation by both A- and C-fiber nociceptors.
     These findings suggest that of the deep tissue of the back, the thoracolumbar fascia is most sensitive to chemical stimulation. Hence, the thoracolumbar fascia probably contributes to nonspecific LBP but not to localized pressure hyperalgesia.

Source: Schilder A, Hoheisel U, Magerl W, et al. Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain. 2013 Sep 25. [Epub ahead of print]

Clinical outcomes in obese patients after total knee arthroplasty

Patients who are considered super-obese (those with a body mass index [BMI] >50 kg/m²) have frequent surgical and medical complications and poor functional outcomes after total knee arthroplasty (TKA), new research demonstrates.
     Investigators assessed the effect of obesity on implant survivorship, complications, functional outcomes, and intraoperative variables (including operative time and estimated blood loss). They compared outcomes in 101 knees of 95 patients (21 men, 74 women) with BMI of at least 50 kg/m² who had undergone primary TKA with outcomes in a group of patients with BMI less than 30 kg/m². Patients were matched by age, sex, preoperative clinical scores, and average length of follow-up.
     With the numbers available for analysis, investigators could not identify differences in implant survivorship. Medical and surgical complication rates were significantly higher in obese patients, however, than in patients with more-normal BMI (14% vs 5%, respectively). Super-obese patients also achieved lower average Knee Society functional scores than patients with normal BMI (82 vs 90 points, respectively) and smaller gains in flexion arc range of motion (14 degrees vs 21 degrees, respectively). Super-obese patients also lost more blood during surgery and experienced longer surgical anesthesia times compared with normal-weight patients.

Source: Naziri Q, Issa K, Malkani AL, et al. Bariatric orthopaedics: total knee arthroplasty in super-obese patients (BMI > 50 kg/m²). survivorship and complications. Clin Orthop Relat Res. 2013;471(11):3523-3530.

Exploring a novel image-guidance system for trauma surgery

A fluoroscopy-based, image-guided system could improve outcomes after orthopaedic trauma surgery, new study findings suggest.
     The prospective study involved 45 patients at a level I trauma center. The guidance system was used during surgery in 12 feet, 10 shoulders, 7 long bones, 7 hands and wrists, 7 ankles, and 4 spines and pelves. Various surgical procedures were analyzed according to the basic principles of the Association for Osteosynthesis/Association for the Study of Internal Fixation Foundation. Main outcome measurements were the number of trials for implant placement, total surgery time, usability as evaluated by surgeon questionnaire, and system failure rate.
     In all cases, surgeons used the trajectory function of the guidance system to insert a total of 56 implants. The system failed when used in patients with pelvic and spinal injuries, resulting in a total failure rate of 7% of all included cases. The overall usability of the guidance system was highly rated, scoring 84%.
     Investigators concluded that the fluoroscopy-based, image-guided system could be integrated into the surgical workflow and was successfully used in orthopaedic trauma surgery. They recommended that advantages should be further explored in randomized studies.

Source: Kraus M, von dem Berge S, Schöll H, et al. Integration of fluoroscopy-based guidance in orthopaedic trauma surgery - A prospective cohort study. Injury. 2013;44(11):1486-1492.

Why don't most runners get knee osteoarthritis?

Peak knee joint contact forces ("loads") during running are much higher than they are during walking, and peak load is associated with the development and progression of osteoarthritis (OA). Nonetheless, runners do not have especially high risk for OA compared with nonrunners. Why?
     Compared with walking, the relatively short duration of ground contact and relatively long length of strides during running seem to blunt the effect of high-peak joint loads, investigators report. Results indicate that calculations of load per unit distance traveled (PUD) are no higher during running than walking.
     The study involved 14 healthy adults who walked and ran at self-selected speeds. Ground reaction force and motion-capture data were measured and combined with inverse dynamics and musculoskeletal modeling to estimate peak knee joint loads, PUD knee joint loads, and the impulse of the knee joint contact force for each gait with a matched-pair (within-subject) design.
     The peak load was 3 times higher during running than walking, but the PUD load did not differ between the 2 activities. The impulse of the joint contact force was greater for running than for walking. Increased running speeds resulted in increased peak loads and decreased PUD loads.
     To study joint loading and injuries, the investigators recommend consideration of waveform features other than or in addition to the peak value.

Source: Miller RH, Edwards WB, Brandon SC, et al. Why don't most runners get knee osteoarthritis? A case for per-unit-distance loads. Med Sci Sports Exerc. 2013 Sep 12. [Epub ahead of print]

Which factors best diagnose traumatic anterior shoulder stability?

Investigators set out to determine the optimal combination of patient information and clinical tests to diagnose traumatic anterior shoulder instability. They discovered that individual clinical shoulder tests provide good diagnostic accuracy. The most important predictors for the condition are young age, history of shoulder dislocation, sudden onset of symptoms, and positive result of the release test.
     Investigators conducted a prospective cohort study that included 169 consecutive patients with shoulder symptoms who were examined at an orthopaedic outpatient clinic. One experienced clinician conducted 25 clinical tests. Six of these assessments were considered to be specific for testing of traumatic anterior shoulder instability: apprehension, relocation, release, anterior drawer, load and shift, and hyperabduction. Investigators used magnetic resonance arthrography to determine the final diagnosis. A prediction model was developed by logistic regression analysis.
     In all, 60 patients (36%) were diagnosed with anterior shoulder instability on the basis of findings obtained with magnetic resonance arthrography. The overall accuracy of individual clinical tests was 81% to 86%. Age, previous shoulder dislocation, sudden onset of symptoms, and results of the release test were important predictors for the diagnosis of traumatic anterior shoulder instability. The prediction model demonstrated high discriminative ability (area under the curve, 0.95).

Source: van Kampen DA, van den Berg T, van der Woude HJ, et al. Diagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability. J Shoulder Elbow Surg. 2013;22(10):1310-1319.

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Boost morale with the "above and beyond" award

A policy to recognize valuable staff members on a regular basis has a powerful effect on morale and office culture. What form should such a policy take? Consider starting an "above and beyond" award that you present to a deserving employee at your regular staff meetings.

How the policy works
     Invite all employees in the practice to nominate, in writing, a coworker for the "above and beyond" award. The award is given to a staff member who does something special or makes an extra effort for a patient or coworker. Nominations should describe why the employee deserves the award. Before the staff meeting, the office manager or practice owner reads the nominations and chooses a winner.
     Purchase gift cards from a popular retail destination (Amazon, Target, or Starbucks, for example) and have the manager or physician present the gift and the honor to the winning employee at your staff meeting. Before the winner is announced, share with all staff members the details as to why the person won. After the meeting, post the winner's name somewhere in the office, such as the staff bulletin board. You may choose to post the name of the current winner or a running list of winners.
     Gift cards in the amount of $25 work well; the recognition is more important than the dollar value of the award. Present only one award per staff meeting, which may be a weekly or monthly occurrence. If you have multiple nominations before a staff meeting, consider saving some for the next meeting.
     The "above and beyond" award will always make staff meetings end on a positive note, even if some of the topics discussed that day were not so positive.

Good deeds are contagious
Because staff members cannot nominate themselves, the award causes employees to pay attention to the good work of others. Staff members who frequently nominate others find that they are then nominated as well as a thank you. Employees who are naturally considerate and frequently go the "extra mile" for patients end up with numerous awards. This makes those who have not received an award try a bit harder to be recognized. The focus is on providing exceptional service, and the award makes everyone think and talk about service.
     In smaller practices, you can recognize and reward staff members for good deeds without having them nominate each other. Just pay attention to jobs that are done well and thank the person with a gift card at a meeting.

Adapted from Neil B. Gailmard, OD, MBA, FAAO, editor, Optometric Management Tip of the Week.

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Please enjoy free access to the article, "Management of Pediatric Type III Supracondylar Humerus Fractures in the United States: Results of a National Survey of Pediatric Orthopaedic Surgeons" from the October/November issue of the Journal of Pediatric Orthopaedics. Free access to this article lasts until your next issue of COP eNews arrives, when you'll receive free access to a new article.

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