Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge current with Orthopaedics in Brief. This month, learn whether barbed or standard sutures are better for wound closure after total knee arthroplasty. Find out which outcomes are associated with total and unicompartmental knee replacement surgery before recommending an operation to patients with end-stage osteoarthritis. Learn whether patterns of traumatic elbow instability correspond to coronoid fracture patterns. Discover the effectiveness of myofascial release for plantar heel pain, whether epidural glucocorticoid with lidocaine is any better than lidocaine alone for lumbar spinal stenosis, and more.

This month's Practice Management discusses texting by staff members and how to prevent cell phone misuse during work hours.

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

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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Delayed ACL surgery increases risk of secondary injuries in children

Pediatric patients who delay anterior cruciate ligament (ACL) reconstruction surgery may be at increased risk for secondary knee injuries, according to research presented in July at the American Orthopaedic Society for Sports Medicine's Annual Meeting in Seattle, Washington. The study results support those of earlier research, which indicated an increased risk of secondary meniscal and chondral injuries in children.
     "In reviewing records of young patients who received ACL reconstructions, our data showed higher rates and severity of secondary meniscus injuries when surgery is delayed," said lead study author Allen F. Anderson, MD, of the Tennessee Orthopaedic Alliance in Nashville. In the study, patients who had surgery 6 to 12 weeks after ACL injury had 1.45 greater odds of lateral meniscal injury, and those waiting 3 months or longer increased their risk 2.82 times. The risk of medial meniscal tears was 4.3 times greater when surgery was delayed at least 6 weeks.
     Researchers analyzed the records of 130 patients between the ages 8 and 16 years who underwent ACL reconstruction. Patients were divided into 3 groups based on timing of surgery. Sixty-two patients were treated less than 6 weeks after injury, 37 were treated 6 to 12 weeks post-injury, and 36 were treated more than 3 months after injury. Most of the patients (64%) were boys.
     Additional risk factors for secondary injuries included younger age, return to sport activities before surgery, and prior knee instability.

Tracking complications after total hip arthroplasty due to acetabular fracture

In a new systematic review involving 659 hips, investigators analyzed the outcome of total hip arthroplasty (THA) after acetabular fracture. Of the studies that reported the acetabular implants used, an uncemented acetabular component was used in 80% of hips (484 of 604), and a cemented component was used in 20% of hips (120 of 604). Of the studies that reported the type of femoral stem used, a cemented femoral stem was used in 60% of procedures (340 of 569), and an uncemented stem was used in 40% (229 of 569). The median Harris hip score was 88 points.
     In the early THA group (Kaplan-Meier survivorship analysis with any loosening), osteolysis or revision as the end point revealed a 10-year cup survival rate of 81%. In contrast, the 10-year cup survival rate was 76% in the late THA group. The 10-year survival rate was 95% for the early femoral stems and 85% for the late ones.
     Because of the complexity of these fractures, investigators recommend that they be managed in highly specialized units where expertise in arthroplasty and trauma reconstruction is available.

Source: Makridis KG, Obakponovwe O, Bobak P, Giannoudis PV. Total hip arthroplasty after acetabular fracture: incidence of complications, reoperation rates and functional outcomes: evidence today. J Arthroplasty. 2014 Jun 12. pii: S0883-5403(14)00397-0. [Epub ahead of print]

Assessing outcomes 10 years after volar locked plate fixation

Operative treatment of unstable intra-articular distal radial fractures (DRFs) with volar locked plate fixation (VPF) is an effective and satisfactory therapy from both functional and quality-of-life standpoints, new study results suggest.
     In the study, 39 patients (average age, 61 years) were treated operatively with VPF after sustaining an intra-articular DRF. Patients were evaluated 2, 6, and 10 years postoperatively using the Gartland and Werley classification system. For subjective evaluation, the 36-item Short Form Health Survey (SF-36) and the Disability of Arm, Shoulder and Hand (DASH) questionnaire were adopted.
     Overall, wrist function did not differ significantly 2, 6, and 10 years after surgery. More than 90% of patients achieved "good" or "excellent" results 10 years after surgery, according to Gartland and Werley scores. Ten years postoperatively, the results of the SF-36 did not differ significantly from those obtained at 2- and 6-year follow-up visits. Overall findings from the SF-36 did not differ significantly from Austrian and American population norms.
     Compared with Austrian population norms, 10-year follow-up results among study participants were significantly poorer only with regard to mental health. Median DASH scores were not significantly different during the 10-year follow-up period.

Source: Ruckenstuhl P, Bernhardt GA, Sadoghi P, et al. Quality of life after volar locked plating a 10-year follow-up study of patients with intra-articular distal radius fractures. BMC Musculoskelet Disord. 2014 Jul 24;15(1):250. [Epub ahead of print]

Barbed versus standard sutures for closure in total knee arthroplasty

Compared with standard sutures, use of barbed sutures in total knee arthroplasty (TKA) is associated with shorter closure time, lower cost, and similar outcomes and complications, according to new findings.
     Investigators prospectively randomized 411 patients undergoing primary TKA to either barbed running or knotted interrupted suture closure. Closure time was measured intraoperatively. Cost analysis was based on suture and operating room expenses.
     Closure time was shorter with barbed sutures than for standard sutures (9.8 minutes vs. 14.5 minutes, respectively). Total closure cost also was less with barbed sutures than with standard ones ($324 vs. $419, respectively). Early complications and outcomes were similar for both groups.

Source: Gililland JM, Anderson LA, Barney JK, et al. Barbed versus standard sutures for closure in total knee arthroplasty: a multicenter prospective randomized trial. J Arthroplasty. 2014 May 27. pii: S0883-5403(14)00353-2. [Epub ahead of print]

Is epidural glucocorticoid for lumbar spinal stenosis effective?

Although it is a common treatment for lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offers minimal or no short-term benefit compared with epidural injection of lidocaine alone, according to a new report.
     In a double-blind trial, investigators randomly assigned 400 patients with lumbar central spinal stenosis and moderate-to-severe leg pain and disability to receive either epidural injections of glucocorticoids plus lidocaine or lidocaine alone. Patients received 1 or 2 injections before the primary outcome evaluation, which was performed 6 weeks after the first injection.
     The 2 primary outcomes were Roland-Morris Disability Questionnaire (RMDQ) score and intensity of leg pain. RMDQ scores range from 0 to 24, with higher scores indicating greater physical disability. Leg pain was measured using a scale from 0 to 10, with 0 indicating no pain and 10 indicating "pain as bad as you can imagine."
     At 6 weeks, no significant differences were observed between the 2 treatment groups in RMDQ scores or intensity of leg pain. A subgroup analysis by type of injection (interlaminar or transforaminal) also demonstrated no significant differences at 6 weeks.

Source: Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11-21. Erratum in: N Engl J Med. 2014;371(4):390.

Evaluating myofascial release for plantar heel pain

Earlier research demonstrated that stretching the calf musculature and the plantar fascia are effective strategies for plantar heel pain. New study results indicate that myofascial release (MFS) reduces the pain and functional disability associated with plantar heel pain more than sham therapy.
     The double-blinded trial involved 66 patients: 17 men and 49 women who had a clinical diagnosis of plantar heel pain. Patients were randomly assigned to receive either MFR or sham ultrasound therapy. Each patient received 12 sessions of treatment during a 4-week period.
     Results indicated that the MFR group performed better than the sham therapy group at weeks 4 and 12. Patients in the MFR and sham therapy groups reported reductions of 72.4% and 7.4%, respectively, in their pain and functional disability at week 4 compared with that at week 1. In the MFR group, a 60.6% reduction in pain and functional disability compared with baseline persisted at the follow-up visit at week 12. Findings also revealed significant group-by-time interactions for changes in pressure pain threshold over the gastrocnemius and soleus muscles and the calcaneus.
     Results indicated that the MFR group performed better than the sham therapy group at weeks 4 and 12. Patients in the MFR and sham therapy groups reported reductions of 72.4% and 7.4%, respectively, in their pain and functional disability at week 4 compared with that at week 1. In the MFR group, a 60.6% reduction in pain and functional disability compared with baseline persisted at the follow-up visit at week 12. Findings also revealed significant group-by-time interactions for changes in pressure pain threshold over the gastrocnemius and soleus muscles and the calcaneus.

Source: Ajimsha MS, Binsu D, Chithra S. Effectiveness of myofascial release in the management of plantar heel pain: a randomized controlled trial. Foot (Edinb). 2014;24(2):66-71.

Patterns of elbow instability correspond to coronoid fracture patterns

Two-dimensional fracture and heat mapping techniques may help predict the distribution of coronoid fracture lines associated with specific injury patterns. In a recent study, investigators demonstrated that specific patterns of traumatic elbow instability have correspondingly specific coronoid fracture patterns.
     Investigators collected 110 computed tomographic (CT) studies of patients with coronoid fractures. Fracture types and injury patterns were characterized on the basis of anteroposterior and lateral radiographs, 2- and 3-dimensional CT scans, and intraoperative findings as described in operative reports.
     Using quantitative 3-dimensional CT techniques, investigators reconstructed the coronoid and reduced fracture fragments. Based on these reconstructions, fracture lines were identified and superimposed onto a standard template to create 2-dimensional fracture maps. To emphasize the fracture maps further, the initial diagrams were converted into fracture heat maps. Fisher's exact test was used to evaluate the association between coronoid fracture types and elbow fracture-dislocation patterns.
     Forty-seven coronoid fractures were associated with a terrible triad fracture dislocation, 30 with a varus posteromedial rotational injury, 1 with an anterior olecranon fracture dislocation, 22 with a posterior olecranon fracture dislocation, and 7 with a posterior Monteggia injury. The association between coronoid fracture types and elbow fracture-dislocation patterns, as shown on 2-dimensional fracture and heat maps, was strongly significant.
     Knowledge of these patterns improves care planning because it directs exposure and fixation and helps to identify associated ligament injuries and fractures that could benefit from treatment.

Source: Mellema JJ, Doornberg JN, Dyer GSM, Ring D. Distribution of coronoid fracture lines by specific patterns of traumatic elbow instability. J Hand Surg Am. 2014 Jul 25. doi:10.1016/j.jhsa.2014.06.123. [Epub ahead of print]

Should you recommend total or unicompartmental knee replacement?

For patients with end-stage osteoarthritis, treatment options include total knee replacement (TKR) or unicompartmental knee replacement (UKR). Findings from a new report that compares adverse outcomes for each procedure can help make the choice between the options a little clearer.
     With propensity score techniques, investigators compared matched patients who underwent TKR or UKR and were registered in the National Joint Registry for England and Wales between 2003 and 2012. Investigators linked data for multiple potential confounders and used regression models to compare outcomes, including rates of revision, revision/reoperation, complications, readmission, mortality, and length of stay.
     In all, 25,334 UKRs were matched to 75,996 TKRs on the basis of propensity score. At 8 years, patients who underwent UKR had worse implant survival, both for revision (subhazard ratio [SHR] 2•12) and for revision/reoperation (1•38, 1•31-1•44), than patients who underwent TKR. TKR was associated with significantly higher mortality than UKR at all time points (30-day hazard ratio: 0•23, 0•11-0•50; 8-year hazard ratio: 0•85, 0•79-0•92). Length of stay; adverse events (including thromboembolism, myocardial infarction, and stroke); and rate of readmission were all higher in patients who underwent TKR than in those that underwent UKR.
     When making decisions about which procedure to recommend to patients, investigators suggest balancing the higher revision/reoperation rate of UKR against lower rates of adverse events, readmission, and mortality, together with known benefits for UKR in postoperative function. If 100 patients undergoing TKR had UKR instead, the result would be approximately 1 less death and 3 more reoperations in the first 4 years after surgery.

Source: Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101?330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet. 2014 Jul 7. pii: S0140-6736(14)60419-0. [Epub ahead of print]

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Texting by staff members: OK or not?

Every practice owner should strive to make the practice a great place to work. If employees have a high level of job satisfaction, they have better attitudes on the job, and patients feel those positive vibes. That said, sometimes the practice owner must set a firm policy and allow no exceptions-even if the policy is unpopular with staff members. Personal smart phone usage by staff members is one of those situations.
     Here's how it often starts: one staff member texts on a mobile phone during some down time. When one employee sees another texting, she assumes it is okay, and she starts doing it as well. Before long, staff members are texting in the presence of patients. Staff members in the same building sometimes even text each other-and these are not work-related texts.

Establishing office policy
Your practice needs a written office policy to prevent texting and cell phone use by staff members during work hours. This policy should be one of your practice's rules of employment that are part of your employee handbook. You can refer to the policy as needed and modify it as new issues arise. Here is an example of an office cell phone policy: "The practice does not allow cell phone use during work hours. Cell phones may not be carried on your person while at work. A locker (or another safe place) is provided to store personal items, and that is where the cell phone belongs. Phones may be retrieved and used at lunch and on breaks away from all patient areas."
     Keep in mind that employees sometimes need to communicate with a family member, such as a child or an elderly parent. There may also be emergencies when the employee must be contacted. Your policy should allow for these occasions, but not via personal cell phones. Advise staff to have those calls come through the main office phone line. A staff member will transfer the call, take a message, or notify the employee to return the call. When communication occurs via the office phone system, it helps prevent abuse and overuse.
     You may want to consider allowing associate doctors and office managers to be exceptions to the no-phone policy, with the understanding that they limit personal cell phone use to private areas. You may want to text these employees for work-related communication.

Instituting the new policy
When you have a cell phone use policy in writing, you will need to announce it to staff members. During a staff meeting, review the new policy and explain why you cannot have cell phone use during work: it is poor customer service and it is not fair to co-workers. Explain that if a manager or practice manager were to observe any employee using his or her cell phone during work hours or in areas of the office visible to patients, that person would be sent home immediately. The employee would have to speak to the practice owner or manager before he or she could return to work.

Addressing related issues
Along with a cell phone policy, consider including a statement that office computers may not be used for personal use or Internet access. Make this policy firm, and do not allow office computer use even when the employee is off duty and punched out. It is too easy to pick up a computer virus or malware when some websites are visited or e-mail is accessed.
     Cell phone use by patients is a related topic. It can be annoying if a patient takes a mobile call or texts during an examination. However, rules of behavior in society are changing, and your practice should try hard to please patients. If a patient's cell phone rings, wait patiently to see if he or she will take the call. If the patient takes the call, say, "I'll give you a moment" and get up to leave the room. This almost always results in the patient ending the call.

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, "Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for the Treatment of Geriatric Distal Humerus Fractures: A Systematic Review and Meta-Analysis" from the August issue of the Journal of Orthopaedic Trauma. 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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