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Volume 5 - Issue 4, August 2012
Current Orthopaedic Practice E-News
Welcome Orthopaedics in Brief Clinical Pearls Article of the Month Practice Management
Editor: Nanci Kulig

Welcome to Current Orthopaedic Practice eNews. Keep your clinical knowledge up to date with Orthopaedics in Brief. This month, discover a novel technique for stabilizing impression fractures of the tibial plateau. Find out whether long-term treatment with denosumab is safe and effective for improving bone marrow density. Learn whether screws or pegs are better for achieving stability of extra-articular distal radial fractures, and more.

Want your practice to make a great first impression? Start by making sure patients see a clean office. Check out this issue's Practice Management column to learn who should be responsible for keeping your office space looking its best.

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

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

Nanci Kulig
Editor, COP eNews

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Multiple ACL surgeries do not restore full activity

Patients who undergo repeated anterior cruciate ligament (ACL) reconstruction are unlikely to return to prior activity levels despite showing basic functional improvement, according to research that was presented in July at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) in Baltimore.
     The study included 15 patients who were undergoing at least their third ACL surgery on the same knee, which is a rarity, according to lead study author Diane Dahm, MD, orthopaedic surgeon from the Mayo Clinic. The study group included 8 men and 7 women who ranged in age from 18 to 57 years. All patients demonstrated a return to basic function based on a collective increase in International Knee Documentation Committee (IKDC) score, from 59 preoperatively to approximately 80 postoperatively. The IKDC system allows patients to self-evaluate their postoperative recovery.
     All patients reported improved outcomes in day-to-day function after a repeat revision surgery; however, only 27% had returned to their preoperative activity level at final follow-up. Patients with grade III or IV chondral injuries or body mass index greater than 28 had worse functional outcomes.
     "While the small number of patients in this study is a limitation," commented Dahm, "the procedure is relatively uncommon and this is the largest to-date. Gathering information on these unique patients is an important step toward understanding how people will function after a repeat ACL surgery." No immediate postoperative complications were noted during the study.

Source: Undergoing multiple ACL surgeries allows patients to regain basic function, but not full activity study shows [press release]. Baltimore, MD: American Orthopaedic Society for Sports Medicine (AOSSM); July 15, 2012.

Volar fixed-angle plating of distal radial fractures: screws vs. pegs

Findings from a recent study suggest that locking screws improve construct stability better than smooth locking pegs for Orthopaedic Trauma Association (OTA) type A3 extraarticular distal radial fractures.
     Eight pairs of fresh-frozen human distal radii were used in the study. Extra-articular distal radial fractures were created and stabilized with a multidirectional volar fixed-angle plate. The radii were randomized into 2 matched-paired groups. In one group, the distal fragment was stabilized with 7 locking screws. The distal fragment in the other group was fixed with 7 locking pegs. The proximal fragment in both groups was fixed with 3 screws.
     Investigators tested the specimens under torsion and axial compression during static and cyclic tests. Finally, load-to-failure tests were performed under torsion.
     After 1000 cycles, 99% of the median torsional stiffness remained in the group stabilized with screws, whereas only 76% of the median stiffness under torsion remained in the group that was fixed with pegs. Under axial compression, median stiffness remained at 93% in the group that received screws after 1000 cycles compared with a median of 0% in the group that received pegs. These findings represent a statistically significant difference between locking screw and locking smooth peg configuration with regard to stiffness of the constructs after 1000 cycles.

Source: Mehling I, Klitscher D, Mehling AP, Nowak TE, Sternstein W, et al. Volar fixed-angle plating of distal radius fractures: screws versus pegs-a biomechanical study in a cadaveric model. J Orthop Trauma. 2012;26(7):395-401.

An Internet treatment for low back pain?

An online occupational postural and exercise intervention reduced patients' overall risk for chronicity in subacute nonspecific low back pain, according to a prospective study involving 100 university office workers. Patients were randomized to an intervention group, which received an online occupational postural and exercise intervention, or to a control group.
     The online exercise and education materials used in the intervention group included video demonstrations recorded in a laboratory. All sessions included exercises combining postural stability (for abdominal, lumbar, hip, and thigh muscles) strengthening; flexibility; mobility; and stretching. Outcome measures included STarT Back Screening Tool (SBST), Roland Morris Disability Questionnaire score, and European Quality of Life Questionnaire -5 dimensions - 3 levels. After 9 months, investigators analyzed and compared SBST results with baseline and controls.
     Investigators observed significant positive effects on average scores recorded in the online occupational exercise intervention group for risk of chronicity. A correlation was noted among functional disability, health-related quality of life, and risk of developing chronic low back pain. Study findings support the use of occupational internet-based intervention to prevent progression of subacute nonspecific low back pain in office workers.

Source: del Pozo-Cruz B, Parraca JA, del Pozo-Cruz J, Adsuar JC, Hill J, et al. An occupational, internet-based intervention to prevent chronicity in subacute lower back pain: a randomised controlled trial. J Rehabil Med. 2012;44(7):581-587.

Novel way to stabilize impression fractures in the tibial plateau

Fractures of the tibial plateau can lead to advanced gonarthrosis if reduction does not restore perfect joint congruency. Various reduction techniques focusing on operative procedures have been described. In a new report, investigators describe a novel technique that was tested in cadavers and has undergone a successful first clinical application.
     Based on the knowledge that kyphoplasty can provide effective anatomic correction in patients with spine fractures, investigators adapted inflatable instruments and used a balloon technique to reduce depressed fragments of the tibial plateau. The technique enables restoration of a congruent cartilage surface and bone reduction.
     Based on their observations, investigators conclude that the new technique is useful in reducing depressed fractures of the tibial plateau. As with minimally invasive procedures, its advantage is minimal damage to other structures.

Source: Ahrens P, Sandmann G, Bauer J, König B, Martetschläger F, et al. Balloon osteoplasty-a new technique for reduction and stabilisation of impression fractures in the tibial plateau: A cadaver study and first clinical application. Int Orthop. 2012 Jun 24. [Epub ahead of print]

Tracking the effects of denosumab on bone mineral density

A new study offers good news to patients who take denosumab to increase bone mineral density (BMD). During 8 years of follow-up, continued denosumab treatment was associated with progressive gain in BMD and persistent reduction in bone turnover markers (BTMs), and it was well tolerated by patients.
     In the 4-year parent study, postmenopausal women with low BMD were randomized to receive placebo, alendronate, or denosumab. After 2 years, women were reallocated to continue, discontinue, or discontinue and reinitiate denosumab; discontinue alendronate; or maintain placebo for 2 more years. The parent study was then extended for 4 years, during which all subjects received denosumab.
     Of the 262 participants who completed the parent study, 138 completed the 4-year extension study. For women who received 8 years of denosumab treatment, BMD at the lumbar spine and hip increased by 16.5% and 6.8%, respectively, compared with their parent study baseline; and by 5.7% and 1.8 %, respectively, compared with their extension study baseline. For the 12 women in the original placebo group, 4 years of denosumab resulted in BMD gains comparable to those observed in participants who received 4 years of denosumab in the parent study. Reductions in BTM were sustained over the course of continued denosumab treatment. Reductions also were observed when the placebo group transitioned to denosumab.

Source: McClung MR, Lewiecki EM, Geller ML, Bolognese MA, Peacock M, et al. Effect of denosumab on bone mineral density and biochemical markers of bone turnover: 8-year results of a phase 2 clinical trial. Osteoporos Int. 2012 Jul 10. [Epub ahead of print]

Managing humeral shaft fractures

Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care, according to a new report that evaluates various ways to manage humeral shaft fractures.
     Surgical management is indicated in specific situations, however, including polytraumatic injuries, open fractures, vascular injuries, ipsilateral articular fractures, floating elbow injuries, and fractures for which nonsurgical management has failed. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing.
     These techniques have advantages and disadvantages, and the rate of fracture union can vary by technique. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, investigators conclude that good surgical outcomes can be achieved with proper patient selection.

Source: Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012;20(7):423-433.

How safe is platelet-rich plasma therapy?

When it comes to treating cartilage tears in athletes, platelet-rich plasma (PRP) therapy is a safe and effective method of treatment, according to research findings presented in July at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) in Baltimore.
     Use of PRP therapy to repair cartilage can significantly improve function and quality of life for patients, according to Elizaveta Kon, MD, lead author for the study and director of the Nano-Biotechnology Laboratory at the Rizzoli Orthopaedic Institute in Bologna, Italy. None of the patients treated experienced complications such as infection, deep vein thrombosis, or fever.
     During the study, 180 patients were treated for chronic pain or swelling of the knee with either PRP therapy or viscosupplementation. A total of 109 patients, with an average age of 56 years, reached final evaluation. Both treatment groups demonstrated significant improvement based on higher post-treatment IKDC scores.
     "As athletic participation has grown," Kon noted, "new problems like cartilage lesions, or tears, continue to emerge. Finding the right approach to treatment is difficult, but PRP has emerged as a viable option according to our research."
     Kon also noted that long-term follow-up studies for PRP treatments are needed to evaluate the overall effectiveness of the therapy for future patients.

Source:" Platelet rich plasma therapy a safe option for cartilage damage, new study finds." American Orthopaedic Society for Sports Medicine (AOSSM) press release, July 14, 2012.

Air-Stirrup ankle brace vs. fiberglass backslab for pediatric ankle fractures

Is the below-knee fiberglass posterior splint as effective as the Air-Stirrup ankle brace to restore normal activity levels to children with a low-risk ankle fracture? Both means of immobilizing the ankle appear equally effective, according to recent study findings.
     In the study involving 45 children, age 5 to 15 years, with a low-risk ankle facture, investigators randomly assigned children to receive either the Air-Stirrup ankle brace or a fiberglass posterior splint. A validated self-reported outcome tool, the Activities Scale for Kids-performance (ASKp), was used to measure physical functioning during a 4-week period. The main outcome was ASKp score at 2 and 4 weeks, with secondary outcomes that included pain, weight-bearing ability, and acceptability of device.
     The median ASKp score at 4 weeks was 91.9 in the brace group and 84.2 in the posterior splint group. Scores on the ASKp, as well as ASKp differences, were favorable toward the brace in the 11- to 15-year age group at 2 weeks (69.6 vs 55.6) and 4 weeks (97.5 vs 90.2) but trended to favor the posterior splint in the 5- to 10-year age group (47.5 vs 56).

Source: Barnett PL, Lee MH, Oh L, Cull G, Babl F. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012;28(8):745-749.

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Maintaining a clean office

A clean office environment should be a given in practices today, but that is not always the case. No practice owner wants to have a dirty office, but when you see the same spaces day after day, it is easy not to notice--or to hope no one else notices.
     However, most patients do notice dust, cobwebs, and dirt, especially if they spend time waiting. Both housekeeping duties and janitorial services require continuous vigilance. Staff members do not usually like housekeeping duties and may think those tasks are not part of their job description, and commercial cleaning services may let attention to detail drop.
     Keep in mind that a clean office can be a competitive advantage over other practices. You will also feel good when a patient mentions the cleanliness of the office.

A dual approach
Housekeeping is best managed with 2 resources: an after-hours cleaning service and daily cleaning by the entire staff. Some offices try to get by with just one of these, but that effort usually falls short. A cleaning service is needed for the tougher areas, such as bathrooms and floors. Nevertheless, you also need regular staff to perform continuous light cleaning such as straightening up the reception area and emptying wastebaskets.
     Janitorial services should clean most offices at least twice per week, when the office is closed. One of the visits could be on the weekend and could be a longer service for deep cleaning. The other visit could be mid-week during the evening. Toilets require thorough cleaning at every visit. The practice owner or manager should check the work quality on a regular basis and communicate with the service if quality slips. Corners and baseboards are areas that are frequently overlooked.
     A truly clean office should not just look clean, it should smell clean. Ask a friend or spouse to perform a smell check on your office upon walking in from outside. Weird odors are common in medical offices, and they are hard to detect when you are too close to them.

Staff support
Communicate to all new employees that housekeeping is part of everyone's job description. Each staff member concentrates more on his or her own work area, but everyone must be on the lookout for problems. Receptionists pay attention to the magazines, the coffee bar, the patient bathroom, and the entry floor tile. Technicians clean examination rooms. Doctors keep their own offices tidy. Everyone empties wastebaskets in his or her area. The staff lounge area has its own rules, with staff members cleaning up after themselves. That said, a rotating daily assignment takes care of general maintenance in the staff room.
     A job that is assigned to everyone will be neglected. Typically, everyone waits for someone else to do it, and no one is really accountable. Avoid that problem by assigning key people to supervise housekeeping throughout the day and to coordinate the efforts of others. Consider making it a policy that staff members do not leave for the day until key cleaning tasks are completed.
     Think about giving every employee specific secondary duties that are expected to be completed daily during times when patient care is not needed. Housekeeping assignments are an excellent side job.

Clutter vs. dirt
All the cleaning in the world does not overcome stacks of papers at the front desk that no one has time to deal with, or electrical cords that run hodge-podge in the examination rooms. Take the time to look at what a patient sees in every area of your office. Remove clutter by discarding old stuff and moving unneeded items to a storage facility. Your office looks much more attractive and efficient if it is neat as a pin.

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

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Please submit any clinical questions you have or any solutions you've found to clinical problems at clinicalpearls@c-orthopaedicpractice.com. We'll do our best to answer your questions and share solutions.

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Please enjoy free access to the article, "Biomechanical Analysis of Pin Placement for Pediatric Supracondylar Humerus Fractures: Does Starting Point, Pin Size, and Number Matter?" from the July/August 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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