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ACS, AAOS, OTA, SOMOS & AASST Prepare for a Disaster; New! Ankle Replacement Guidelines; New Study: XLPE Wear Rates

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, January 25th, 2017

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ACS, AAOS, OTA, SOMOS and AASST Prepare for a Disaster

David C. Teague, M.D. is the Don H. O'Donoghue Professor and Chair of Orthopaedic Surgery at the University of Oklahoma. Dr. Teague is on the AAOS (American Academy of Orthopaedic Surgeons)/OTA (Orthopaedic Trauma Association) Disaster Preparedness Project Team empaneled to refine national recommendations for disaster relief and mass casualty preparedness.

Dr. Teague told OTW, “Margaret ‘Peggy’ Knudson, M.D., of the ACS (American College of Surgeons), and I are co-chairing a multidisciplinary collaborative workgroup focused on the broad topic of domestic disaster preparedness. We are attempting to work within the broad house of surgery including especially general surgeons and orthopedic surgeons at the outset. Domestic preparedness work necessarily requires multiple disciplines (e.g., anesthesia and neurosurgery), but galvanizing the efforts of the ACS and the AAOS along with the several specialty organizations is the focus of the initial work.”

“There are approximately 12 outstanding organizations that have within their portfolios some element of disaster preparedness, either educational or disaster response. We have been tasked by the ACS, AAOS, OTA, The Society of Military Orthopaedic Surgeons (SOMOS), and The American Association for the Surgery of Trauma (AASST) with bringing all of those efforts under the same tent.”

“Initially, we have three primary areas of focus.”

The first is to coordinate collective disaster education courses and develop a clearinghouse where they are all listed. Also part of this would be development of a ‘just in time’ basic module for those considering getting into action.”

“The second part is a qualified disaster responder registry which ideally will include trained professionals across multiple specialties. We will ultimately work toward legislation that will allow qualified surgeons and teams to respond domestically even across state lines when situations mandate, respecting of course local and state jurisdictions.”

“Thirdly, we will promote a broader exposure of the ‘Stop the Bleed’ campaign that the ACS has developed in conjunction with other stakeholders, going directly to the public instead of teaching only professional responders. We are taking this route because it is now clear that civilians can save civilian lives (using tourniquets, for example).”

“We now have workgroups meeting via conference call. They are working on the development of online or similar real-time courses that we hope can be available free of charge. Our goal is to take the best elements of our collective disaster courses and merge them into a platform to help first responders respond to terror.”

“Much of our past educational platform has been centered on ‘This is what you do to get a team ready for Haiti or Nepal.’ Now we need a set of modules on real-time domestic preparedness and a commitment to constant domestic readiness.”

“Hospitals and trauma centers in any given city need to work with regional and local partners including law enforcement. Often only law enforcement personnel may be allowed into an intentional trauma scene before it is secure enough for paramedics, and those officers may provide life-saving interventions for victims.”

“If local resources are overwhelmed, we need a process to both send victims to remote treatment facilities and bring in trained providers to assist local teams.”

“Dr. Knudson is a recognized leader in this field. We in the OTA, AAOS and SOMOS are fortunate to have great partners at the ACS and other surgical specialty organizations. We look forward to ongoing collaborative progress in 2017.”

JBJS Publishes Ankle Surgery Guideline

It’s a win-win situation for patients and surgeons alike. Thanks to the initiative of an orthopedic surgeon at Mount Sinai in New York City, we now have a standardized way for surgeons to help patients dealing with painful ankle replacements.

Ettore Vulcano, M.D. is assistant professor of Orthopaedics at the Icahn School of Medicine at Mount Sinai. He told OTW, “I had the privilege to train with one of the most eminent foot and ankle surgeons in world, Mark Myerson, M.D. I always say that he has radar-like hands and eyes, and can diagnose the most peculiar conditions. Because the experience of someone at his level really can’t be taught, I developed the idea of guidelines that could inform even the least experienced foot and ankle surgeons. One day I began jotting down possible reasons—other than infection—why a total ankle may be especially painful. Then Dr. Myerson, co-author of the study, reviewed and modified the algorithm.”

The algorithm, just published in the January 4, 2017 issue of The Bone & Joint Journal, will help surgeons decide on the most appropriate revisions. Dr. Vulcano noted, “I have received numerous inquiries from industry representatives and colleagues who like it and/or are interested in learning the indications for the algorithm.”

“The guidelines should serve as reassurance to surgeons and patients. Surgeons will no longer feel like they are drowning in a sea of differential diagnoses; with the guidelines they can address the problem systematically and objectively.”

“This will result in cost savings because you can likely avoid things such as blood work and magnetic resonance imaging (MRI). I see so many patients who had MRIs or computed tomography (CT) scans, but have never had a good weight-bearing X-ray.”

“As for patients, the guidelines provide a sense of ease because they feel like their physician has a plan.”

New Study: XLPE Wear Rates

Do patients undergoing primary total hip arthroplasty (THA) with larger articulations and highly cross-linked polyethylene (XLPE) have higher wear rates than those with standard-diameter articulations?

New research from Australia has delved into that very question. The research, initiated by Professor Donald Howie, clinical director of the Royal Adelaide Hospital Orthopaedic and Trauma Service, involved 56 elderly patients who underwent THA and were separated into two groups: those who received a 36mm or a 28mm metal-on-XLPE Articularion.

Stuart Callary, B.App.Sc. is a medical scientist with the Department of Orthopaedics and Trauma at Royal Adelaide Hospital. He told OTW, “We had undertaken a large multi-centre randomised controlled trial to examine the effect of articulation size on the incidence of dislocation within the first year following total hip arthroplasty.”

“That trial showed that patients with a primary THA with a 36mm metal-on-highly cross-linked polyethylene articulation were more than five times less likely to dislocate than those with a 28mm articulation (0.8% vs 4.4%). However, larger diameter THAs incorporating conventional polyethylene had been shown to have greater rates of wear than those with standard diameter articulations.”

“Therefore, we undertook a randomised controlled trial to compare the wear rates of 36 and 28mm metal-on-highly cross-linked polyethylene articulations in primary THA.”

“Radiostereometric analysis (RSA) is a highly specialised radiographic technique which is recognised as the most sensitive measure of polyethylene wear in vivo and this technique was used to measure polyethylene wear in this trial.”

“One of the highlights of this work is that early in vivo wear rates of metal-on-cross-linked polyethylene articulations are low and early wear rates of larger articulations are no greater than those of standard-sized articulations. Also, THAs with larger articulations are appropriate for use in elderly patients and those at increased risk of dislocation, but longer term outcomes are required before their use can be widely recommended in younger patients.”

We found that the mean annual proximal, medial, 2D and 3D polyethylene wear rates of the 36mm articulations were not significantly greater than those of the 28mm articulations.”

“Of most interest—and reassurance—was our finding that no patient with either a 36 or 28mm articulation exceeded a proximal wear rate of 0.1 mm/year, this rate being the previously established threshold for an increased risk of developing osteolysis in THAs incorporating conventional polyethylenes.”

“We plan to continue following up these patients using RSA to measure longer term wear rates.”

“This is important because the orthopaedic community needs to know whether the low early wear rates of highly cross-linked polyethylene are maintained in the long term. We also plan to use RSA to compare wear rates of younger and older patients undergoing THA.”

“Younger patients are thought to have higher levels of activity, which may increase wear. Given the increasing numbers of younger patients undergoing THA and their increased life expectancy, it is important to establish whether there is an association between age and polyethylene wear. In addition, we intend to examine the relationship between peri-prosthetic osteolysis and wear of highly cross-linked polyethylene.”

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