Monthly Archives: September 2016

Thromboprophylaxis in Orthopaedic Surgery

Richard J. Friedman, MD, FRCSC

Saturday, March 5th, 2011

Abstract

Venous thromboembolism is a serious complication after total hip or knee surgery and there is a well-established clinical need for thromboprophylaxis. However, in a large number of cases adequate administration of thromboprophylaxis does not seem to occur after total joint arthroplasty. A major challenge in the management of thromboprophylaxis is to balance the benefits of treatment with the risks, including bleeding complications. Another potential barrier to the optimal use of thromboprophylaxis could be the inconvenience of currently available agents. Many surgeons therefore adopt a conservative approach towards thromboprophylaxis. Simplifying therapy with more convenient, efficacious and safe anticoagulants could change attitudes to anticoagulant use, and improve adherence to thromboprophylactic guidelines.

Introduction

Venous thromboembolism (VTE) is a serious complication after major orthopaedic surgery [1]. The rates of venographic deep vein thrombosis (DVT) and proximal DVT 7 to 14 days after major orthopaedic surgery in patients who receive no thromboprophylaxis are approximately 40% to 60% and 10% to 30%, respectively [1]. The manifestation of DVT is, to some extent, a consequence of bone damage during surgery, when procoagulant debris triggers thrombin generation, resulting in hypercoagulability [2]. In addition to hypercoagulability, the other components of Virchow’s triad of venous stasis and endothelial damage are also thought to play a part in thrombosis [3]. Thus, there is a well-established clinical need for thromboprophylaxis after arthroplasty [1].

A major challenge in the management of anticoagulants is to balance the benefits of treatment with the risks, including bleeding complications. Many surgeons appear concerned about postoperative bleeding and tend to adopt a conservative approach towards the relative risks and benefits of thromboprophylaxis [2]. Consequently, although evidence-based guidelines and recommendations advocate the use of anticoagulants after major orthopaedic surgery, thromboprophylaxis is still used suboptimally [4–6]. However, the evidence that careful prophylaxis administered at an appropriate time after surgery causes surgical bleeding is sparse [7]. In this review, current trends in thromboprophylaxis after orthopaedic surgery in the United States (US) are described. Factors limiting appropriate implementation of thromboprophylaxis regimens are also discussed 

Current Standard of Care

Further to the consensus document developed by the National Institute of Health in 1986 [8], there have been a series of American College of Chest Physicians (ACCP) guidelines published on the use of pharmacological agents for thromboprophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA), last updated in 2008 [1].

In the US, the available options for anticoagulation and thromboprophylaxis after elective THA or TKA are the vitamin K antagonists (VKAs, e.g. warfarin), the low molecular weight heparins [LMWHs]), and fondaparinux (an indirect Factor Xa inhibitor). Each of these options is associated with significant limitations that complicate use in clinical practice. VKAs have been the mainstay of oral anticoagulant therapy for more than 60 years [9]. However, VKAs have unpredictable pharmacokinetics and pharmacodynamics, and significant inter- and intrapatient variability in dose–response relationships. They are associated with multiple drug–drug and food–drug interactions and have a narrow therapeutic window [9]. Regular coagulation monitoring is therefore required to ensure that the international normalized ratio is within the recommended range of 2.0 to 3.0. The heparins are administered subcutaneously, which means patients often require daily appointments or a nurse visit to administer their medication. LMWHs are also associated with the risk of developing heparin-induced thrombocytopenia [10]. Fondaparinux is also administered subcutaneously, and is contraindicated in patients with severe renal impairment and in those that weigh less that 50 kg. In patients over the age of 75 who have undergone THA or TKA, fondaparinux causes an increased risk of bleeding [11].

The timing of initiation of prophylaxis depends upon the type of anticoagulant used. Warfarin therapy is generally initiated prior to surgery because of its delayed onset of action, whereas prophylaxis with LMWH can be started 10–12 hours before or 12–24 hours after surgery. There does not seem to be a clear advantage with either regimen, and both regimens are recommended by the ACCP [1]. Thromboprophylaxis is recommended to continue for at least 10 days after joint replacement surgery, with extended prophylaxis for up to 35 days recommended for those patients undergoing THA surgery and with a suggestion that thromboprophylaxis for up to 35 days could be beneficial for those undergoing TKA [1]. Traditionally, thromboprophylaxis used to continue only until the patient was discharged from hospital [12], despite the fact that this could be a suboptimal duration [13] and the risk of DVT and mortality after discharge is considerable [14, 15]. The median length of stay in US hospitals is now as short as 3 days after THA and 4 days after TKA [16]. A retrospective study of the medical records of 3,778 orthopaedic surgery patients found that 88% were discharged from hospital and prescribed warfarin or acetylsalicylic acid [6].

Suboptimal Utilization of Thromboprophylaxis

Despite the fact that thromboprophylaxis is now recommended for routine use after total joint arthroplasty, it is not always used optimally. Approximately 10% of patients received inadequate in-hospital thromboprophylaxis, and approximately 33% received inadequate post-discharge thromboprophylaxis according to findings from the US Hip and Knee Registry (1996–2001) [17]. An analysis of the data from the multinational Global Orthopaedic Registry (GLORY) to evaluate the compliance of surgeons with the ACCP guidelines for the prevention of VTE showed that only 47% of THA patients and 61% of TKA patients received prophylaxis in accordance with the recommended start time, duration and dose/treatment intensity recommended by the guidelines [16]. Although nearly all patients received prophylaxis on the first day after surgery, more than a quarter did not receive any form of prophylaxis 7 days after surgery [18].

 

Suboptimal thromboprophylaxis decreases patient outcomes, resulting in many patients remaining at unnecessary risk of thrombosis and its complications [4]. The reasons for lack of compliance with the guidelines may be numerous. They include lack of awareness, poor understanding or disagreement with guidelines (either specifically or as a general concept), resistance to changing established practices, and doubt that a new approach will change outcomes. Established surgeons may also be reluctant to use new anticoagulant regimens because of a fear of increased bleeding risk [17]. Attitudes may also limit a physician’s willingness to follow guidelines. An awareness of the guidelines does not necessarily mean physicians have sufficient knowledge to critically evaluate and apply recommendations [4].

Other potential barriers include the mistaken belief that a small asymptomatic DVT is not important because it cannot cause clinically significant pulmonary embolism (PE) [19], which fortunately is only held by a minority [20]. Due to the often clinically silent nature of VTE, and the low incidence of VTE during the short postoperative hospital stay, the chances of a surgeon witnessing a major DVT or an acute PE are rare [4]. In addition, the trend towards earlier hospital discharge means that many symptomatic events occur after that time [21, 22], and patients are often seen by other specialists when referred back to hospital with a venous thromboembolic event; therefore, surgeons are often unaware of the true incidence of VTE in their patients.

Long-term sequelae of VTE are frequent and often disabling [23]. Recurrent VTE can occur after surgery, although the incidence is less than in other patients groups such as those with cancer [24]. Thrombosis damages the deep venous valves resulting in venous reflux and venous hypertension of the lower limbs. This residual venous obstruction and inflammation are thought to be responsible for the development of post-thrombotic syndrome [25, 26]. Chronic thrombotic pulmonary hypertension, which is associated with considerable morbidity and mortality, occurs in approximately 3–4% of patients over 2 years after a symptomatic PE [27].

Economic Impact of Venous Thromboembolism

The acute and chronic phases of VTE related care have substantial economic consequences [28, 29] that can be effectively modeled [30]. A recent study found the total annual healthcare cost for a VTE ranged from $7,594 to $16,644, depending on the type of event and whether it was a primary or secondary diagnosis. The hospital readmission rates for DVT or PE within 12 months were 5.3% for primary and 14.3% for secondary diagnoses [31]. These data indicate that thromboprophylaxis with anticoagulants should not only be beneficial to patients, but could also be cost effective for the healthcare system [32, 33].

Need for More Convenient Anticoagulants

Another potential barrier to the optimal use of thromboprophylaxis could be the inconvenience of currently available agents [34]. Orthopaedic surgeons and their patients would benefit from an oral anticoagulant that could be administered in fixed doses [35].

Simplifying Therapy

Non-compliance can result in a poor quality of life and increased medical expenditures in managed care. In a study of diabetic patients, total medical costs were approximately $4,500 for patients at 80–100% adherence compared with approximately $8,900 for those at 1–19% adherence [36]. A variety of factors affect non-compliance, but simplifying treatment has been shown to improve adherence in asthma patients [37] and cardiovascular patients given single-pill amlodipine/atorvastatin were found to be approximately three times more likely to achieve adherence over 1 year of follow-up than patients given a two-pill regimen [38]. Similarly, simplifying therapy to a once-daily regimen in virologically suppressed HIV-1-infected patients improved adherence and patient satisfaction [39].

Novel Anticoagulants

Anticoagulants in development are targeting different steps in the coagulation pathway to provide simpler alternatives to currently available anticoagulants. Among these new agents are direct thrombin inhibitors and direct Factor Xa inhibitors [40]. The direct thrombin inhibitor dabigatran etexilate appears an attractive alternative to the current standard of care in patients after THA and TKA [41–44]. It has been granted marketing authorization in the European Union and Canada for the prevention of VTE after THA or TKA. The manufacturer’s recommended dose is 220 mg once daily (starting 1–4 hours after surgery with a single 110 mg capsule) for a total of 28–35 days after THA or a total of 10 days after TKA [45]. Direct Factor Xa inhibitors in development include rivaroxaban, apixaban, edoxaban (DU-176b), and YM150, and of these rivaroxaban is in the most advanced stage of development [46]. Rivaroxaban has shown potential as a once-daily, oral anticoagulant that may be administered in fixed doses for the prevention and treatment of thromboembolic disorders following orthopedic surgery [47–52]. Rivaroxaban is approved in more than 90 countries worldwide, including the European Union and Canada, for the prevention of venous thromboembolism after elective hip or knee replacement surgery in adult patients. A dose of 10 mg once daily (with the initial dose 6–10 hours after surgery, provided that hemostasis has been achieved) for 5 weeks after elective hip arthroplasty or 2 weeks after elective knee arthroplasty is recommended by the manufacturer [53].

 

The main difference between direct thrombin inhibitors and direct Factor Xa inhibitors is their mechanism of action. They also differ in their pharmacokinetic and pharmacodynamic profiles, such as metabolism. For example, in the case of dabigatran, more than 80% of the systemically available drug is eliminated by renal excretion [54]. Two–thirds of administered rivaroxaban is metabolized to inactive metabolites (half of this is eliminated via the kidneys and half via the fecal route), and one–third is excreted as unchanged active drug in the urine [55].

 

Conclusion

The need to use thromboprophylaxis after major orthopaedic surgery is now becoming well recognized. However, adequate administration of thromboprophylaxis regimens does not seem to occur after total joint arthroplasty in a large number of cases. The reasons for this appear complex, involving surgeons’ poor awareness of the problem of post-surgical thrombosis, their attitudes to guidelines, concerns about causing bleeding, and the complexities of anticoagulation with current agents. Simplifying therapy, such as once–daily fixed dosing, could change attitudes to anticoagulant use and improve adherence to guidelines. Newly developed, oral, fixed-dose anticoagulants should enable substantial improvement in thromboprophylaxis usage, thereby improving patient outcomes. The primary drawback of the new anticoagulants, particularly those with a long half-life, is the lack of specific antidotes to reverse their anticoagulant effect[56]. Specific antidotes might be needed in particular situations such as for overdose or emergency surgery. However, this may not pertain to dabigatran and rivaroxaban as they have relatively short half–lives (12–14 hours and 7–11 hours, respectively) [45, 53]. As off-label prescribing is not uncommon, there is a risk that new anticoagulants licensed for thromboprophylaxis after THA or TKA will be prescribed for unlicensed indications [57]. These current challenges could be overcome by finding specific antidotes and post-approval surveillance of off-label prescribing.

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Dr. Friedman is a Clinical Professor of Orthopaedic Surgery at The Medical University of South Carolina and Chairman of the Department of Orthopaedic Surgery of Roper Hospital, Charleston, SC, USA.  He is a world reknown leader in the prevention of deep vein thrombosis.

A Triumph of Matter over Mind

by Augusto Sarmiento, MD

January 25th, 2014 

The current pervasive and misguided infatuation with the idea that in the care of fractures it is indispensable to achieve perfect restoration of anatomy in all instances in order to obtain good clinical results continues to blind many in our profession. I have previously made reference to this obsession suggesting that we train our residents to be cosmetic surgeons of the skeleton rather than physicians/scientists1.

My belief that Orthopaedics is losing its scientific primacy and rapidly becoming an entirely technical discipline was reinforced a short time ago when I learned of a clinical situation where passion prevailed over reason with very likely adverse serious consequences.

The clinical case consisted of a 21 year old man who was involved in automobile accident rendering him paraplegic. In addition he had suffered bilateral comminuted, distal intraarticular fracture of both forearms. The fractures were treated by means of internal fixation using plates and screws as well as multiple pins that held together the diligently repositioned small fragment. Radiographs obtained following surgery demonstrating excellent reduction of the fractures.

For reasons not known to me, the surgeon chose to improve upon the fixation achieved from the plates and screws by placing on the dorsum of the patient’s right arm a long plate that extended from the neck of the third metacarpal to the mid-radius. Several screws filled the holes in the long plate. This plate, I was told, would be removed six weeks after surgery; therefore I assumed it was not intended to encourage fusion of the wrist.

I cannot express strong disagreement with the procedure performed for the care of the radius fractures that must have taken a great deal of time plus the likely possibility that the extensive dissection of the bony fragments could result in major stiffness of his wrists joints. After all this is the current party line. However, I cannot help but question the wisdom of inserting a plate that inevitably will increase the degree of limitation of motion of the wrist from which the patient will never completely recovered.

This very realistic scenario provokes an even greater discomfiture when one realizes that the young man was paraplegic and will remain paraplegic for the rest of his days. As such, his only mode of locomotion will be a wheel chair, from which he will transfer to his bed and automobiles. A bit of thought should have made the surgeon aware that transfer activities from a wheel chair require a significant degree of dorsiflexion of the wrists. In order to lift one’s body with the use of the hands, dorsiflexion of the wrists is essential. The young man, I anticipate, will not be able to do so, and if he masters s technique to accomplish the task it will be a very complicated and difficult one.

I have surmised that the surgeon performing the surgery was very likely a technically skillful one, but either because of his blind reliance on the virtues of internal fixation and perfect reapproximation of fragments, or lack of objectivity, he has condemned a young man to a disability greater than the one that the paraplegia had already imposed on him.2. It does not suffice to adhere to the aphorism expressed by Simon Bolivar, the Latin American liberator, “Good judgment comes from experience and experience comes from bad judgment”, at least not when we are dealing with the health and future of other human beings.

The rampant lack of objectivity, clearly demonstrated in this instance, can be improved if we, the educators, emphasize objective reasoning to our students. Unharnessed enthusiasm and fascination with surgical experiences must be tempered with reason. “La raison avant la passion”.

REFERENCES:

1.   Sarmiento A. The future of our specialty. Acta Orthopedica Scandinavica. 71 (6): 574-579, 2000

2.   Sarmiento A. Have we lost Objectivity?  Jour. Bone and Joint Surgery. Vol. 84A:  1254-58, 2002.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

The Dangers of Unchallenged Tradition

by Augusto Sarmiento, M.D

November 27th, 2013 

     Since for the first time I find myself with time in my hands I decided to dwell on exploring issues with which in the past I was involved to a major degree. Today I will discuss an issue where long-held, rigid adherence to an unchallenged tradition has forced me to challenge its validity.

My comment deals with the Colles fractures, which is one of the first subjects in orthopaedics we come into contact during our year of internship.  We learned about the ubiquitous fracture that affected a large number of older people and were told that its treatment was simple and the clinical results good.  All that was needed:  “closed reduction” and immobilization in a long arm cat for a few weeks.

It was not until late in my career that I first began to ask questions as to the etiology of the frequently observed loss of the obtained reduction. I had followed the gospel-like lessons we had learned from the British orthopaedist who forcefully stated that once the reduction had been obtained, the cast had to extend over the elbow, the forearm held in pronation and the wrist in a position of ulnar deviation and slight flexion.

One day, however, I suspected that the recommended position of the foreman in pronation in the cast was the guiltiest party. My logic was based on my understanding of the anatomy and physiology of the wrist. I reasoned that if it is true that muscles in order to function most effectively should be placed in a condition of tension then the forced pronation of the forearm would result in activation of the brachioradialis muscle, the only muscle attached to the distal radius, and in that manner recreate the deformity. The contraction of this muscle during flexion of the elbow could easily displace proximally and dorsally the distal radial fragment. 1

I met with the neurologist who was performing electromyography and asked him for his advice and help. I brought him volunteer medical students and patients to have the studies conducted.  Without exceptions, every time the elbow was flexed the brachioradialis muscle contracted. In cadaver specimens, where we had created fractures that resembled the Colles fracture pattern, any pull on the muscle readily recreated the typical deformity.

Based on all that information we began to treat Colles fractures in supination and compared the results with those obtained when treated in pronation. The results were published, which indicated a lower incidence of re-displacement in the supination group. We went as far as developing a foreman brace that permitted limited flexion of the elbow, but prevented pronation of the forearm. It permitted limited flexion of the wrist but made impossible any radial deviation. 2, 3 I concluded that the classical position as described by Colles and faithfully accepted by the orthopaedic community was wrong.

At that time my career took a major turn toward Hip surgery following  a three-month visit to Sir John Charnley in England that resulted in my concentrating more seriously on total hip replacement and ignoring to some degree my interest in wrist fractures. I deeply regret the foolish decision since I am sure I could have been able to continue to devote time to both subjects simultaneously.

I vividly recall that during those days of romancing with Colles fractures I visited with some regularity local Nursing Homes where I followed patients I had treated surgically for various conditions. Oftentimes I took along with me one or two residents. During those visits I made it a habit to ask as many patients as possible if they had at any time in their lives sustained fractures of their wrists. As expected, many of them had. I saw many where a close look failed to indicate any deformity whatsoever. Other times I observed obvious deformities.  However, I have no recollection of a single patient who presented symptoms of osteoarthritis or complained of any serious clinical problems as a result of the deformed wrist.

No doubt, my mind was conditioned not to question the wisdom of Colles and consequently I had rigidly adhered to his well-intentioned but erroneous premise. I suspect we do this very often with many other pronouncements and treatment which overtime gain an odor of sanctity that precludes questioning. This is why I am such a strong advocate of conditioning residents to ask questions and to challenge virtually everything we teach them.

During the last two decades a great deal of enthusiasm has grown in support of open reduction and internal fixation of Colles fracture. The readers would not be surprised to hear that I have not surrendered to the new treatment modality. However, I trust I am smart enough to realize that the technique has made possible the attainment of better anatomical reduction and restoration of articular congruity and in many occasions is the treatment of chicer. 

        Approximately 10 years ago I sustained a comminuted, intraarticular Colles fracture with a severe dislocation of the radio-ulnar joint.  My hand surgeon fixed the fracture with multiple wires. When I woke up from the surgery and glanced at the radiographs I immediately commented “This will never work.” My remark was based on the recognition that the dislocated radio-ulnar joint had not been addressed. The surgeon had concentrated on reduction of the fragments in the best possible way, but ignored the dislocation of the ulna, which was the most important feature. Good fragment reduction in the presence of a dislocated radio-ulnar joint is not enough, particularly if the distal-lateral radial fragment has an oblique geometry. The reduction is easily lost when the brachioradialis contracts    . That was exactly what happened. Ten days after surgery new x-rays demonstrated the recurrence of the radial deviation of the held-together distal epiphysial bones. Soon after that I was back in surgery where a plate was used to stabilize the bony fragments.

My feeling regarding the closed treatment of Colles fractures may soon become meaningless since the current infatuation with surgery is displacing the nonsurgical treatment into the heap of history. Or maybe not. We should not be surprised if within a few years the orthopaedic profession will conclude that plating was nothing but a flash in the pan when the technique is applied to all displaced fractures and that plate fixation should be reserved for the very severely comminuted fractures with associated radio-ulna dislocation. We are already learning that the results from routine surgery are not any better than those obtained from manipulation and close reduction. Economics may the fact that triggers the arresting of the trend. Equal pay for the care of those patients may become the law of the land regardless as to whether or not surgery is performed.

REFEERENCES:

  1. Sarmiento, A. The Brachioradialis as a Deforming Force in Colles’ Fractures Clin. Orthop. Rel. Res. 38:86-92, 1965.
  2. Sarmiento, A., Pratt, G.W., Berry, N.C. and Sinclair, Wm. F. Colles’ Fractures – Functional Bracing in Supination. J. Bone and Joint Surg. 57A:3,311-317, 1975.
  3. Sarmiento, A., Zagorski, J.B. and Sinclair, W.F. Functional  Bracing of Colles’ Fractures: A Prospective Study of Immobilization in Supination versus Pronation.  Orthop. & Rel.  Res. 146:175-187, 1980

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

Saving Time and Making Better Informed Clinical Decisions

by Donna Flake, MSLS, MSAS, Director, SEAHEC Medical Library, Wilmington, NC 

Medical Librarians CAN save you time AND assist you in making better informed clinical decisions.

Medical Librarians have an essential role in health care.  They provide evidenced-based medical information to health professionals, enabling them to make better informed clinical decisions.

A recent JAMA article (Sept. 25, 2013), “The Evolving Role and Value of Libraries and Librarians in Health Care,” reported on a study of health professionals in which 71% of the respondents said they changed how they managed the care of a particular patient as a result of information provided by the health science library.

At many medical centers, medical librarians are actually going on rounds with physicians and medical residents, then providing evidenced-based medical information on the medical cases studied.  I did this with the Pediatric physicians and residents in a former job.

A landmark study was published in the Journal of the Medical Library Association in January 2013.  It demonstrates the importance, value, and cost savings of medical libraries, and medical librarians.  16,122 physicians, nurses, and other health professionals at 118 hospitals in the US and Canada responded to the survey.  The survey was designed to determine whether information obtained from library services was perceived as valuable and if the information was considered to have impacted patient care.  Here are some of the results:

  • 7% felt the impact was significant enough to reduce patient length of stay
  • 56% felt the knowledge helped avoid adverse events, such as hospital readmission, patient mortality, and additional procedures
  • 92% of health professionals said medical information provided through library services provided new knowledge
  • 95% of health professionals said medical information provided through library services resulted in the provider making a better informed clinical decision
  • 85% of physicians believed the information from the library saved, on average, 2.5 hours of their time
  • 84% of health professionals felt the knowledge contributed to a positive change in patient care, such as advice given to patient or choices of drugs

In Spring, 2013, I completed a user satisfaction survey on the SEAHEC Medical Library in Wilmington, NC.  Of the physicians who responded, 95% agreed that the information the library provided would have been difficult to obtain on their own.  Additionally, 75% agreed that the information the library or the library databases provided influenced decisions on patient care.  Below is a sampling of comments from my user satisfaction survey:

  • A physician stated:  “The library has been invaluable for research projects and articles submitted for publication.”
  • An OB/GYN resident stated:  “The librarians are very knowledgeable and helpful with journal articles and literature searches.”
  • A physician stated:  “The librarians provided excellent, prompt help.”
  • A nurse administrator stated:  “I’d never be able to find what I want due to lack of knowledge and/or time constraints.  My job would be so much more difficult without the library services.”
  • An administrator of the Emergency Department stated:  “Love our library, we couldn’t do without it.”

I encourage readers of this blog to contact their medical librarians – great things can happen!

Sources:

Sollenberger, J, Holloway, R.  The evolving role and value of libraries and librarians in health care.  JAMA Sept 25, 2013 310 (12): 1231.

Marshall, J, Sollenberger J, Easterby-Gannett S, et al.  The value of library and information services in patient care:  results of a multisite student.  J Med Lib. Assoc 2013 101 (1): 38-46.

Mrs. Flake is Library Director at the SEAHEC Medical Library in Wilmington, NC and renown for her work with libraries around the world.

Dr. Black Elected Second President-Elect of the American Orthopaedic Association

August 25th, 2013 

by Kari McLean, American Orthopaedic Association

Congratulations to Kevin P. Black, MD on being elected Second President-Elect during the 126th Meeting of The American Orthopaedic Association, in Denver, Colorado in June of 2013.  He will become First President-Elect at the 2014 Combined Meeting of The American Orthopaedic Association and the Canadian Orthopaedic Association in Montreal, Canada, June 17-21, 2014, and will assume the role of AOA President in June 2015.

Career Highlights:

  • McCollister Evarts Professor and Chair of the Department of Orthopaedics and Rehabilitation at Penn State Milton S. Hershey Medical Center with a special interest in Sports Medicine
  • Vice Dean for the Penn State University College of Medicine
  • Certified by the American Board of Orthopaedic Surgery
  • MD degree from the Medical College of Wisconsin; orthopaedic residency at the University of Rochester School of Medicine & Dentistry; and Fellowship in Sports Medicine at the Cleveland Clinic Foundation
  • Developed the Sports Medicine Program at the Medical College of Wisconsin
  • Penn State Hershey Medical Center Awards
    • Distinguished Educator Award
    • Steven Baron Leadership Award
    • 2013 President of the Pennsylvania Orthopaedic Society
    • Member and former Director of the American Academy of Orthopaedic Surgeons
    • Member of the American Orthopaedic Society for Sports Medicine
    • Traveling Fellowships
      • AOSSM European Traveling Fellowship
      • Clinical Orthopaedic Society Traveling Fellowship
      • American Orthopaedic Association Service
        • Academic Leadership Committee
        • Council of Orthopaedic Residency Directors (CORD)
        • Chair of the 2010 Resident Leadership Forum
        • Traveling Fellowship Committees

The American Orthopaedic Association (AOA), founded in 1887, is the oldest national orthopaedic association in the world. The AOA’s mission is to identify, develop, engage and recognize leadership to further the art and science of orthopaedics.

Hensler Bone Press Launched in December 2012

May 1st, 2013 

by Sean Hensler, PA-C (Neurosurgery) and Thomas Melin, MD (Neurosurgeon)

Wilmington, NC, USA: The Hensler Bone Press launched in the United States and in select countries internationally on December 18, 2012. It is a Class 2, 510K exempt device, FDA-approved for use. European launch is expected in March of 2012 following CE certification. Contact information for a trial is available on OrthopaedicLIST.com.  Then do a Quick Search for Hensler Bone Press to go to that listing.

During the course of many operative procedures, bone is removed with the use of high speed drills. The bone removed with this technique is usually discarded. Unfortunately, this discarded bone is an excellent source of autologous bone graft for fusion procedures — if separated from blood and other tissues. The Hensler Bone Press (HBP) is a new, innovative device proven to maximize the collection and separation of this previously discarded material to yield high quality autologous bone graft. This device produces compressed, viable autologous bone which is immediately available for use. Many orthopedic, neurosurgical, maxillofacial and podiatry cases involve bone fusion where bone grafting is mandatory. Though many options for bone graft exist, autologous bone graft is universally accepted as the “gold standard”. All other options (synthetic and biologic) attempt to duplicate the characteristics of autologous bone but none has achieved all of these characteristics. This fact, coupled with the high cost of synthetic and biologic grafting options, renders them inferior to autologous bone graft. Though this device may not completely eliminate the need for synthetics or biologics, it will significantly diminish the use of these products. In summary, the HBP is an easy to learn, cost effective device proven to yield high quality autologous bone graft, which will decrease, if not eliminate, the need for synthetic and biologic options.

Founded in May 2011, Hensler Surgical Products, LLC is a Wilmington, NC-based medical device company dedicated to finding and developing innovative products that help to cut costs within health care. Friends and colleagues, Sean Hensler, a Neurosurgical Physician Assistant, and Dr. Thomas Melin, Neurosurgeon, formed Hensler Surgical Products, as a way to conceive, develop and introduce leading surgical innovations into the medical field. Hensler Surgical’s first product to market is the Hensler Bone Press, an innovative 2 stage device, designed to both collect and separate blood from valuable autologous bone generated by the high speed drill during surgical bone fusion grafting procedures while not interrupting the flow of the case.

Regaining Shoulder Range of Motion

July 11th, 2012 

 by James D. Hundley, MD

During my first year of residency, Dr. Charles Neer, a famous shoulder surgeon, was our visiting professor.  We learned a lot from Dr. Neer but the idea that stuck with me forever was his simple technique for regaining shoulder range of motion following surgery.

Dr. Frank Wilson, our training chief, was very influential with his description of the shoulder capsule as being analogous to the leaves of an accordion.  You had to tease them apart bit by bit.  Except in rare cases, he frowned on manipulation under anesthesia.

Keep in mind that this is about regaining functional use of the shoulder in average people after a fracture or other injury and surgery.  It is not about regaining strength other than in daily use of the limb and it’s certainly not about the definitive rehabilitation of athletes.

Naturally I must insert a disclaimer:  I am not your treating physician.  I am simply telling you what has worked for my patients for many years.  Your treating physician is the one you should listen to primarily.  Consider these ideas as supplementary or complimentary to what you’ve been told.

Here are some ideas to keep in mind:

  1. Neer
    1. Most use of the shoulder is to put the hands in front of the body so if you can reach up in front enough to get to a cabinet above eye level and reach down to your lap, you can do most of what you want to do.
    2. A simple way to accomplish this is to grasp your palms together and interlock your fingers.  Straighten the elbows.  Then use the normal arm to lift the hurt one.  It works better if you lie supine since once you get to 90 deg. of forward flexion, gravity will assist you rather than fight you.
  2. Wilson
    1. Steady, almost constant, gentle stretching is needed, is generally safe, and can be very effective.
    2. You need to move your shoulder often, not just once a day or so when a therapist is there to help you.
    3. Manipulation under anesthesia seems fast but carries the risk of muscle and tendon ruptures as well as fracture.  Furthermore, after a manipulation there is a tendency to quickly return to the pre-manipulation contractures
  1. Hundley
    1. Passive range of motion precedes active range of motion.  “Passive range of motion” means that something moves the affected limb other than the muscles of that limb.  In these techniques you are using your good arm to move your bad one.  “Active range of motion” may be contraindicated following some operations (rotator cuff repair for example) and fractures.  Listen to your surgeon about when you can start active motion.  Unless you regain passive range of motion, there is no chance of regaining active range of motion.
    2. Flexion to get the arm overhead also helps with external rotation.  Concentrate on flexion and don’t worry much about external rotation.  It will follow.
    3. It absolutely helps to lie supine to use gravity when using the Neer technique.  Otherwise, “gravity uses you”.
    4. If you will prop your arm away from your body (pillows or arm rest or arm over the back of a sofa when sitting, elbow on a table or desk), you can change your starting point from down by the side to a better place.  That gives you a head start and helps tease those sticky layers of capsule apart.
    5. Be innovative.  Figure out ways yourself to stretch your arm forward and upward.  Reach up to a tree limb, bar, door jamb, whatever it takes, and hold on to it for as long as possible.
    6. Internal rotation is another matter.  You have to make that happen.  The best way is to reach the bad arm as far behind your back as you can and grasp the wrist of the bad arm with the hand of your good arm.  Initially it will be just pulling to get it behind your body.  Ultimately you need to start lifting the hand up the back until you get it as high as the hand of the good one will go.
    7. Physical Therapists are very important in the rehabilitation process.  If you depend on them to do all of the work, however, you are missing many opportunities to help yourself do better.  They can treat you once every day or two.  You need to be moving your shoulder almost all of the time.
    8. Finally, here’s something to keep in mind about healing and my concept of “cumulative pain”.  The body is a remarkable organism and starts trying to heal things almost the instant it is injured.  That includes surgery.  Healing starts with bleeding followed by formation of scar tissue and so on.  If you wait until the pain of injury/surgery has subsided before you do any serious movement of a joint, I think that there is a 100% chance of it scarring down and never moving well.  Early motion is critical.  Cumulative Pain:  I’ve always told my patients that the pain of regaining motion in injured joints can be equated to the pain of walking barefooted across a bed of hot coals.  If you go slowly, I believe that you will hurt longer than if you push through the pain and go faster.  Thus, your ultimate pain burden will be less if you move on and get it over with.  That’s not to say that you can regain your motion in a day, but you probably do need to regain it in two or three weeks.  Once four to six weeks have passed, you have a big mountain to climb.

Summary

  1. You can and need to help yourself regain motion in your shoulder after injury or surgery.  Your therapist is important but cannot do it all for you.
  2. If you are doing your own pulling, you may cause pain but you are unlikely to harm yourself.
  3. Time is critical.  You cannot wait weeks and weeks to regain substantial range of motion.
  4. Forward flexion is the most important movement.  Do this by grasping the hands together and lifting the good arm with the bad.  This is easier when lying supine than when vertical.
  5. Prop your arm away from your body as often, as far, and for as long as you can.
  6. External rotation tends to improve along with forward flexion, so concentrate on forward flexion.
  7. Internal rotation needs special attention.  Regain that by pulling the wrist of the bad arm behind and then up the back with the good hand.
  8. Check with your physician/surgeon before doing these exercises and do not begin lifting the bad arm with its own muscles without your surgeon’s approval.

 Dr. Hundley is a retired orthopaedic surgeon and is the president of OrthopaedicLIST.com.

HINARI: Journals and Books to Physicians in the Poorest Countries

June 19th, 2012 

by Donna Flake, MSLS, MSAS, Director, SEAHEC Medical Sciences Library

The World Health Organization (WHO) has created a tremendously innovative and benevolent program to help physicians, researchers, clinicians, students and health administrators in resource-poor countries.

In a partnership with numerous Scientific, Medical and Technical publishers, WHO provides access to thousands of full-text medical journals and medical books to these constituencies worldwide.  This is done through an internet based program called HINARI (www.who.int/hinari).

The program began in 2002, when WHO contacted key publishers, and requested access to e-journals and other resources.  Today over 150 publishers make their electronic publications available through HINARI.  The program includes access to over 8,500 full text journals, and over 7,000 full text medical books.  This greatly changed the playing field for the health practitioners trying to keep abreast of the medical literature.

Here is how a user from a resource-poor country can obtain access to the HINARI collection of full-text books and journals:

A physician at a medical institution contacts the HINARI program at the World Health Organization and registers for a login and password.

Accesses full-text articles, books and other electronic resources from the HINARI website.

Searches PubMed from the United States National Library of Medicine using the HINARI access code.

Pulls up full text journals and books through PubMed.

Of course there are still some obstacles to using HINARI including irregular supply of electricity, lack of hardware and insufficient bandwidth.

WHO is reaching out to teach members how to access the HINARI collection.  There are many trainers all over the world.  I received HINARI training at a conference of the Medical Library Association in 2009.  The purpose of the training was to instruct individuals from industrialized countries so that they could train partners from low-income ones.  In June 2009, I traveled to Moldova in Eastern Europe, and trained 23 health professionals at the Medical University of Moldova, and 20 health practitioners from the Free International University of Moldova. The class participants were very grateful for the HINARI program, and my training.  My SEAHEC Medical Library in Wilmington, NC has an international partnership with the Medical University of Moldova.  Silvia Ciubrei, Deputy Director of this library, is now a HINARI super trainer for the World Health Organization and travels to Eastern Europe and Russia for the purpose of providing training to health practitioners.  She speaks Romanian, English, and Russian, so her language skills are highly valued.  Silvia is also an excellent teacher.

The WHO divides the countries of the world into 3 categories:

In low-income countries, health practitioners have free access to HINARI.  (One example is Haiti).  More than 5,000 institutions in these countries have HINARI access.

In emerging countries, each institution must pay $1,000.00 per calendar year.  One example of a country in this category is Ukraine.  More than 1,388 institutions in these countries have access.

Richer countries – no access to HINARI.

Orthopedic materials in HINARI include:

Acta Ortopedica Brasileira

Advances in Orthopedics

BMC Musculoskeletal Disorders

Case Reports in Orthopedics

Chiropractic & Osteopathy

Chiropractic and Osteopathy

Clinical Medicine:  Arthritis and Musculoskeletal Disorders

Indian Journal of Orthopaedics

Internet Journal of Orthopedic Surgery

Internet Journal of Rheumatology

ISRN Orthopedics

Journal of Indian Rheumatology Association

Journal of Orthopaedics

Open Access Rheumatology:  Research and Reviews

Open Rheumatology Journal

Revista Brasileira de Reumatologia

Revista Colombiana de Reumatologia

Revista Cubana de Ortopedia y Traumatologia

Romanian Journal of Rheumatology

For more information on HINARI – www.who.int/hinari

 

Mrs. Flake is the Director of the SEAHEC Medical Library in Wilmington, NC, USA.  She has received numerous awards for her accomplishments including being named a Distinguished Member of the Academy of Health Information Professionals.

Why Use A Medical Library

March 15th, 2012 

by Donna Flake, MSLS, MSAS, Director, SEAHEC Medical Science Library

Physicians can save time and obtain current, evidence-based medical information from their medical librarians.  Many physicians feel compelled to seek medical information on their own, even though they are always pushed for time.  Many physicians simply “google” the topic.  However, Google contains fewer than 30% of the medical literature much of which is out of date and incorrect.  Some physicians use PubMed from the National Library of Medicine.  PubMed is a great database but contains very few full text journal articles.

I encourage physicians to contact the medical library nearest to them, and check out what is available.  I am Library Director at a SEAHEC Medical Library in Wilmington, N. C.  Our library has integrated its digital library inside the Electronic Health Record (HER) of New Hanover Regional Medical Center in Wilmington, N. C.  Physicians can go into the EHR, click on my library’s digital library and use:  over 2000 full-text journals, 60 full-text books, the evidence-based product DynaMed, the Cochrane Database of Systematic Reviews, and much more.  My local orthopedists can use this method to access these journals FREE OF CHARGE:

  • Clinical Orthopedics and Related Research
  • Clinical Journal of Sport Medicine
  • Journal of Bone and Joint Surgery (both American and British)
  • Journal of Orthopaedic Trauma
  • Spine
  • and more

A few other U. S. medical libraries that also have integrated their digital libraries inside the EHR of the hospitals they serve include:

  • Vanderbilt University Medical Center in Nashville
  • University of Pittsburgh Medical Center
  • Oregon Health and Science University Hospital in Portland
  • University of Washington Medical Center in Seattle

If your local medical library has not integrated its digital library into its hospital’s EHR, there are other methods of accessing your library’s digital content.  Many hospital libraries and university medical libraries put their digital content on the hospital’s or university’s intranet, and physicians can access it this way.

Your medical library can save you time, money and effort.  A 2011 survey of U. S. health practitioners revealed

  • 75% of survey respondents said “I handled an aspect of a clinical situation differently as a result of having information provided by a librarian, or the library”.
  • 1 hour to 2 hours 30 minutes of time was saved by health professionals using the librarian or the medical library rather than seeking the information on their own.

I also conducted a medical library-user survey at my hospital.  Doctors and other health care providers responded.

  • 59% of survey respondents indicated that information from library services influences decisions in patient care.
  • 73% of survey respondents indicated that information from the library would have been difficult to obtain on their own.

In summary, I encourage you to contact your medical library to see how you can use its services!  A medical librarian could be your best friend!

Mrs. Flake is the Director of the SEAHEC Medical Library in Wilmington, NC, USA.  She has received numerous awards for her accomplishments including being named a Distinguished Member of the Academy of Health Information Professionals.