First-Ever Study: Two-Stage Revision Arthroplasty in Obese Patients
Bacteria abounds, as do questions about treating those infected with one type or another. Chad Watts, M.D., an orthopedic surgery resident with Mayo Clinic, wanted to learn more about this issue regarding a specific population—morbidly obese patients who undergo two-stage revision arthroplasty. He tells OTW, “When a total knee replacement fails due to infection, the gold standard is to remove the knee replacement, insert a temporary spacer containing an antibiotic, and then perform a revision arthroplasty once the infection has been treated. This method successfully cures infection in up to 90% of patients in general. We know that obese patients are at higher risk of infection following knee replacement, but we do not know how well we are able to cure infected knee replacements in this specific population. The epidemic of overweight individuals has exploded over the last ten years or so, which makes this information of interest to surgeons who perform total knee arthroplasty.”
“We went through all of our patients at Mayo who had undergone a two-stage revision for an infected knee replacement and found all of the morbidly obese patients with at least five years’ follow-up. Only those patients who were being revised for the first time were included.”
“Our study group included 111 patients, 37 in the morbidly obese group and 74 in the non-obese group. We found that the morbidly obese patients had significantly higher rates of revision, reinfection, and reoperation as compared with their non-obese peers.”
“We were surprised to find that, although morbidly obese patients had more than a one in four chance of having a subsequent infection following two-stage revision, most of these infections occurred years later and were caused by different bacteria than the initial infection. This suggests that we were able to successfully treat the initial infection for most of these patients, but they unfortunately remain at high risk of acquiring additional infections down the road.”
“It’s also interesting to note that while reinfection was a major cause of failure in the morbidly obese patients, there were also many aseptic or mechanical failures. When a surgeon is treating an infection, he or she should not lose sight of alignment and mechanical integrity of the final reconstruction.”
“The burning question here is, ‘How can we medically optimize morbidly obese patients prior to operating on them in the first place?’ Obviously, it’s not practical to deny surgery to a patient who is sick with an infection, but we can probably do more to improve health and reduce risk prior to performing elective arthroplasties. Should there be a cutoff for BMI [body mass index] such that someone above level X is denied surgery? Should these patients automatically be referred to a nutritionist? What lab values or objective indicators can we follow to more specifically stratify a patient’s risk? Insurers and hospital groups are already imposing cutoffs for BMI, a trend that seems to be spreading. The trouble is that not all morbidly obese patients are the same, but a wide spectrum of relative health exists even within this patient population. There are other factors such as diabetes, nutrition and protein status, fat distribution, and other comorbidities which can further affect risk for complications such as infection. With further research, hopefully we can begin to answer some of these questions.”
Should Orthopedic Surgeons and Psychiatrists Have Same Training Hours?
A new study by a seasoned orthopedic surgeon has found some grumbling amongst orthopedic residents and program directors. William Levine, M.D., the Frank E. Stinchfield Professor and Chairman of Clinical Orthopedic Surgery at Columbia University, decided to put some hard numbers to the things he was hearing from trainees, residency directors, and fellowship directors. Dr. Levine tells OTW, “As an educator and advocate for residents, my fellow educators and I find nothing more challenging than the work hour changes implemented by the Accreditation Council for Graduate Medical Education (ACGME). One of the things that has been lost in the public discussion is that all of medicine has been painted with the same brush. Does it really make sense that residents in pediatrics, psychiatry, and orthopedic surgery for example, all have the same number of training hours per week? Surgery involves being in the operating room…we don’t have the luxury of proscribed hours to the extent that other specialties do. Fellowship directors have been saying that residents are showing up to fellowship ill prepared. And, these directors are saying that they have much less confidence in these new fellows than they had in those of generations gone by.”
“We in New York had been living with the 2003 ACGME 80-hour work week regulations for some time because of the Libby Zion case where a young woman died while under the care of residents. But the 2011 work hour changes have tightened the reins even further and are causing multiple problems to many parties. If you look at the Libby Zion case, the investigating commission determined that the incident really had little to do with work hours. Bertrand Bell, M.D., who headed the commission, emphasized that while the hours were long, it was the lack of supervision that was the issue. The ACGME took that information, and, realizing that it was difficult to mandate supervision, instead implemented regulation of work hours.
“In 2011 the ACGME acknowledged the supervision problem, but again, not knowing how to mandate supervision, instead restricted PG-1 residents (“interns”) to 16 hours a day. Residency directors and attendings are saying that the intern year has become more like the fifth year of medical school. The interns can’t be on call or stay overnight at the hospital. They are forced into a shift mentality, which ultimately means that the continuity of care is diminished.”
“We asked residents and residency directors if the new ACGME duty hour rules from 2011 were improving residency education…66% disagreed. When asked if limiting interns to 16 hours/day was positively impacting their education only 10% agreed. And when asked if the new rules improved residents’ operative experience, 72% disagreed.”
“On the patient care front, we asked if they thought the new rules improved patient safety…54% said ‘no.’ And ‘patient safety’ is the ACGME mantra. When asked if the increased patient handoffs are detrimental to patient safety and quality care 76% said ‘yes.’”
“I serve on the American Board of Orthopaedic Surgery and, along with the American Academy of Orthopaedic Surgeons and the American Orthopaedic Association, many of us are working hard to ensure that patients have a safe treatment experience. I would like the ACGME to understand that these new rules have not achieved what they had hoped for, and in fact, have caused quite a lot of trouble.”
“Years ago we didn’t have an epidemic of poorly trained surgeons. I’m not suggesting that we return to 120 hour work weeks, but something must be done. It’s time that we take this situation and use it as an opportunity to advocate for our patients and trainees.”
Boot Camp: Orthopedic Surgeons From Abroad Learn Research, Operative Techniques
Far be it for those at the Institute for Global Orthopaedics & Traumatology (IGOT) to fly in with good intentions and a scalpel and leave. The IGOT team, headquartered at the University of California (UCSF)/San Francisco General Hospital (SFGH) Orthopaedic Trauma Institute, is doing its part to reduce foreign surgeons’ need for external assistance. Ted Miclau, M.D., professor and vice chair of the UCSF Department of Orthopedics at the University of California, San Francisco (UCSF), is an Executive Member of IGOT. He tells OTW, “We recently held our 5th annual International SMART (Surgical Management and Reconstructive Training) course, an event where surgeons from under-resourced countries come to learn and train. This year we welcomed 51 surgeons from 18 low- and middle-income countries.
“The course, taught by 40 volunteer faculty from UCSF and the University of Southern California, and Stanford, included instruction on a variety of rotational flap techniques for upper and lower extremities. It’s one thing to be able to put a bone back together with hardware and another thing to protect the bone with soft tissue so as to diminish the chance of infection and increase the chance of healing. Participants then travel to Richland, Washington, where they take Lew Zirkle’s SIGN IM Nail course. It’s a whirlwind few days, but these surgeons are thrilled to be able to gain this knowledge…especially knowing that once they get home they can apply it immediately. This is sustainable program building.”
“The last day was devoted to a course on how to conduct clinical research. At the end of this boot camp session the surgeons presented their study designs. Their goal was to develop a project that they could easily bring home and work on. For example, one surgeon’s project will be to look at the effect of amputations on families and another plans on developing a registry for open fractures that come into his hospital.”
“From our end, we are so pleased to have created a highly practical learning experience that is in line with our mission of empowering surgeons around the world to provide better care for their patients. In the past we have had surgeons who have attended the course cry because the experience was so important for them.”
