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From Bench to Bedside: Patience is a Virtue—A Time to Reflect and Reevaluate Surgical Indications

Potter, Benjamin K. MD, FACS

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Clinical Orthopaedics and Related Research: September 2020 - Volume 478 - Issue 9 - p 1981-1983
doi: 10.1097/CORR.0000000000001328
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I am writing this column in late April 2020, in the middle of the first true pandemic in more than a century, that of coronavirus disease 2019 (COVID-19). Most of our usual surgical practices have been dramatically altered or, in some cases, shut down entirely. While this will no doubt create a glut of elective procedures when we eventually get through it, it’s also clear enough that “business as usual” may not look the same when we do.

The Centers for Disease Control and Prevention and the American College of Surgeons have recommended that elective surgery be postponed, with urgent and emergent procedures proceeding more or less as usual [1, 3]. However, a large gray area exists in terms of medically necessary, time-sensitive procedures [5] that may proceed despite not being deemed urgent, and various tools that have been created to assist with triage processes [1, 10]. “Elective” itself is a bit of a misnomer; “scheduled” or “discretionary” are probably better. The urgency and acuity of the surgical indications, particularly for chronic problems, often permit us some flexibility with regard to timing. As the vast majority of procedures performed by orthopaedic surgeons are (hopefully) medically indicated, now seems like a particularly apropos time to evaluate just how medically necessary and time-sensitive these procedures are.

Let’s take the issue of displaced midshaft clavicle fractures, a common injury whose treatment is controversial. A recent meta-analysis published in Clinical Orthopaedics and Related Research® confirmed what most of us believe—that operative treatment may decrease nonunion rates for these injuries [2]. However, the authors also noted that the improvement in clinical outcome scores following surgery did not reach the threshold of minimum clinically important difference (MCID), and that 10 fractures would need to be treated surgically to prevent a single nonunion [2]. Enter a recent prospective study of 200 fractures that suggests we can reliably predict which fractures will heal at 6 weeks from injury. If two or more risk factors (QuickDASH score ≥ 40, absence of callous on radiographs, and/or fracture movement on clinical exam) at 6-week follow-up, they found a > 60% rate of nonunion versus only a 3% rate of nonunion if no risk factors were present. The area under the curve for this model was also greater at 6 weeks than at time of injury (87% vs. 65%) [9]. This may suggest, not that we should avoid operating on these factures, but rather that we can do a better job of determining which patients and fractures should be treated with surgery.

There are many other injuries and maladies where similar approaches may be worthwhile. For example, several meta-analyses have found no benefit to surgery in terms of outcome scores in patients treated for acromioclavicular separations [11, 13]. Despite methodological flaws, and the dated status of some of the included studies (highlighting the need for additional, rigorous study [2]) clearly many of these injuries do not benefit from surgery, and we could potentially improve patient-reported outcomes overall by selectively operating on patients with persistent symptoms later.

Radial nerve injuries following humeral shaft fractures are another example that highlights this conundrum (or opportunity) quite nicely. Most of these fractures heal uneventfully, with good clinical outcomes, without surgery, and most of these nerves will spontaneously recovery. One meta-analysis reported that 77% of patients recover spontaneously without surgery, while 68% recover with exploration beyond 8 weeks, and a 90% recover with early exploration of the nerve [6]. A first impression might suggest that we should just explore these injuries surgically, and that is indeed what those authors recommended. However, another meta-analysis with similar findings recommended observation [9]. Independent of the selection bias implicit in these cohorts, one could putatively (and mathematically, albeit in simplistic fashion) get to a favorable neurologic recovery in 93% of these injuries by exploring just the approximately one injury in four that has not recovered by 8 weeks from injury. Further, what we are really trying to discern early on is nerve incarceration in the fracture site (since overt nerve transections may get repaired, but will likely require tendon transfers regardless), and this can likely be ascertained noninvasively via careful ultrasound or MRI. Likewise, open tibia fractures without early signs of healing were, formerly, routinely treated with staged bone grafting at around three months due a high risk of nonunion. A happy byproduct of the SPRINT study, which forbade intervention before 6 months in an effort to preserve homogeneity between reamed and unreamed tibial nail cohorts, found that the frequency of dynamization, exchange nailing and/or bone grafting could be reduced by more than 50% compared to historical controls simply by waiting [12]. Even for TKA, one large study reported that nearly 26% of those who underwent surgery may have done so prematurely, based on mild symptoms [4], not unlike the mild persistent symptoms many patients experience after TKA. These patients were thus subject to the risks of a major operation for minimal to no clinical benefit, in lieu of waiting and continued nonoperative management.

As we move from era to era—initially one of surgical paternalism, then one of informed consent, and most recently shared decision-making [5, 10]—we need to be more cognizant and objective in terms of “selecting,” and counseling, patients who should have surgery, patients who might benefit from surgery later if things don’t improve, and patients who probably shouldn’t have surgery at all. This calls for a paradigm shift from “this injury/problem requires surgery” (or not) or “failing conservative management” [16]. The result could be enormously worthwhile—less surgery and risk, (modestly) delayed surgery for a few, and better patient-reported, pain and/or functional outcomes overall. As we slouch towards the Bethlehem of a post-COVID-19 era, with surgeons and patients alike having been forced to wait to perform and receive surgery, we have a unique opportunity to reflect, re-evaluate, and re-engage with our practices and our patients with a renewed goal of providing the most good for the most patients. After all, patience is a virtue, and patients are why we are here.

References

1. American College of Surgeons. COVID-19: Elective Case Triage Guidelines for Surgical Care. Available at: www.facs.org/covid-19/clinical-guidance/elective-case. Accessed April, 2020.
2. Axelrod DE, Ekhtiari S, Bozzo A, et al. What is the best evidence for management of displaced midshaft clavicle fractures? A systematic review and network meta-analysis of 22 randomized controlled trials. Clin Orthop Relat Res. 2020;478:392-402.
3. Centers for Disease Control and Prevention. Healthcare Facilities: Preparing for Community Transmission. Available at: www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fguidance-hcf.html. Accessed April 14, 2020.
4. de Sa DL, Bhandari M. Cochrane in CORR®: Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults. Clin Orthop Relat Res. 2020;478:462-468.
5. Elster EA, Chung K, Potter BK. Response to the COVID-19 by the surgical community. Surgery. [Published online ahead of print March 31, 2020]. DOI: 10.1016/j.surg.2020.03.011.
6. Ghomrawi HMK, Mushlin AI, Kang R, Banerjee S, Singh JA, Sharma L, Flink C, Nevitt M, Neogi T, Riddle DL. Examining the timeliness of total knee replacement among patients with knee osteoarthritis in the US: Results from the OAI and MOST longitudinal cohorts. J Bone Joint Surg Am. 2020;102:468-476.
7. Gurich RW Jr, Cizik AM, Punt SE, Namekata M, Johnson CN, Symons RG, Brewer EG, Thompson MJ. Decision-making in orthopaedic oncology: does cognitive bias affect a virtual patient’s choice between limb salvage and amputation? Clin Orthop Relat Res. 2020;478:506-514.
    8. Illyas AM, Mangan JJ, Graham J. Radial nerve palsy recovery with fractures of the humerus: an updated systematic review. J Am Acad Orthop Surg. 2020;28:e263-e269.
      9. Nicholson JA, Clement ND, Clelland AD, MacDonald D, Simpson AHRW, Robinson CM.. Displaced midshaft clavicle fracture union can be accurately predicted with a delayed assessment at 6 weeks following injury: A prospective cohort study. J Bone Joint Surg Am. 2020;102:557-566.
      10. Prachand VN, Milner R, Angelos P, et al. Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. J Am Coll Surg. [Published online ahead of print April 9, 2020]. DOI: 10.1016/j.jamcollsurg.2020.04.011.
      11. Ring DC, Dobbs MB, Gioe TJ, Manner PA, Leopold SS. Editorial: How the words we use affect the care we deliver. Clin Orthop Relat Res. 2016;474:2079–2080.
      12. Shao YC. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87:1647-1652.
      13. Slover J, Shue J, Koenig K. Shared decision-making in orthopaedic surgery. Clin Orthop Relat Res. 2020;470:1046-1053.
      14. Smith TO, Chester R, Pearse EO, Hing CB. Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base. J Orthop Traumatology. 2011;12:19-27.
        15. Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibal Fractures (SPRINT) Investigators. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008;90:2567-2578.
          16. Tamaoki MJ, Lenza M, Matsunaga FT, Belloti JC, Matsumoto MH, Faloppa F. Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults. Cochrane Database Syst Rev. 2019;10:CD007429.
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