One in Six Women With Fracture Are Victims of Domestic Violence
Mo Bhandari’s colleagues know him as a consummate researcher. What they may not know, however, is that he is tackling an aspect of orthopedics that few have dared to approach—domestic violence. Mohit Bhandari, M.D., professor and research chair in Orthopaedic Surgery at McMaster University in Canada, says that he had a ‘Eureka’ moment ten years ago during his subspecialty training. “I was working in Minneapolis and we started seeing quite a number of seriously injured women who got that way at the hands of their domestic partners. I began working with a domestic abuse project and a lightbulb came on…’Wait. Women are not being asked about this. This is not on our radar as orthopedic surgeons.’ I did a couple of early studies, which culminated in our recently published paper in the Lancet…it is the largest multinational study of its kind to date. Alarmingly, we found that one out of every six women who arrive at an orthopedic fracture clinic report domestic violence. Our work is an attempt to get the orthopedic community and major orthopedic associations to take a position and make concrete recommendations on this topic.”
Clearly, Dr. Bhandari chose a hot button issue that many orthopedic surgeons would rather leave to someone else. “Yes, in this male-dominated profession there was initially resistance, largely due to a lack of understanding about how prevalent these injuries are. ‘This is a social services issue, ’ many of my colleagues said. Surgeons are data driven, and so we had to do clinical studies in order to demonstrate the urgency.”
“Even after the data ‘spoke, ’ I would hear, ‘But I see 100 patients in a short period of time. I don’t have the resources to manage this…and what happens if the patient says that she is being abused?’ It became clear that orthopedic surgeons must have a pathway for handling these situations. We began connecting domestic violence groups with surgeons, and creating intimate partner violence tools. One poster available to surgeons shows a woman with a broken bone and says, ‘Not every broken bone is due to a fall.’”
Dr. Bhandari says, “If a woman comes in with a suspicious injury and is accompanied by a partner, you will need to speak to her privately. Our surveys indicate that if the doctor raises the issue of women feeling safe in their home, a woman might have taken that opportunity to reveal the abuse. And interestingly, two-thirds of women said that an orthopedic surgeon is the doctor who should bring up this topic. An E.R. doctor is not the ideal person because the patient spends so little time with that person.”
Knowing his colleagues need specifics on handling these situations, Dr. Bhandari notes, “Once a woman reveals the abuse, then you must reassure them that they need not go back to the unsafe environment and you all will be making a safety plan. Secondly, it is important to reinforce that the abuse is not her fault. Then, you should ensure that she has appropriate referral to services with expertise in domestic violence. Even if the woman doesn’t reveal the abuse until her fourth visit with you, if you are caring and open at every interaction then that person is more likely to think, ‘If I am going to tell anyone it will be today, it will be this doctor, and I will be protected.’”
And how is his work being received? “In 2009 the Canadian Orthopaedic Association developed a position statement on intimate partner violence. The American Association of Orthopaedic Surgeons has had an official position on this for years. I think that as a result of this paper it has reenergized the concern about this issue. This should alarm all of us. Escalating physical injuries is the strongest predictor of intimate partner homicide; and when you get to the stage of a broken bone there’s not much further to go. This is a call to duty for our profession.”
Some Surprises in AAOS’s new Clinical Practice Guidelines
The verdict? Hyaluronic acid is still no magic bullet. The American Academy of Orthopaedic Surgeons (AAOS) has just released its revised clinical practice guideline (CPG) on the treatment of osteoarthritis (OA) of the knee. There were two primary changes. One relates to acetaminophen: The recommended dosage was reduced from 4, 000 mg to 3, 000 mg a day. This is not a change made by AAOS specifically for OA patients, but an overall change made by the FDA since 2009 for individuals who use acetaminophen. The other change is that intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee. (The 2009 guidelines review was inconclusive regarding this treatment method.) David S. Jevsevar, M.D., M.B.A., is chair of the AAOS Evidence Based Practice Committee, the entity that oversees the development of clinical practice guidelines. He told OTW, “The AAOS CPG was initiated and redone because of concerns about the data analysis (developed by the Agency for Healthcare Research and Quality) used by the original workgroup. All studies that met the study selection criteria were reviewed and utilized if acceptable. The AAOS CPG process uses a ‘best available evidence synthesis, ’ limiting bias and heterogeneity of studies. The workgroup also based analysis of study results with the determination of clinical significance. In these studies where the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores were reported, MCII (minimally clinically important improvement) was used to determine and define patient benefit. This is different from many other meta-analyses that use statistical significance as the endpoint.”
“This CPG just summarizes the relative lack of effect for patients. Since the pain and disability associated with knee OA can change daily, and despite the observation that most patients wish to avoid surgery, HA was not proved to be effective for relief of pain and improvement in function. Patients should discuss this treatment with their physicians before undergoing these injections. It is ultimately the patient’s choice to use HA.”
Unlocking the Code to Genetic Therapies in Orthopedics
Javad Parvizi, M.D., director of research for The Rothman Institute in Philadelphia, is going off the beaten musculoskeletal path to find solutions for orthopedic conditions. Epigenetics, says Dr. Parvizi, will lead us toward unforeseen treatment possibilities. “In the old days our understanding of genetics was rather primitive. Over time we have come to realize that it is not just inheriting the gene that determines its expression, but that the environment plays a critical role as to whether the gene is or is not expressed. The recognition of the fact that environmental factors like food can alter gene expression has given rise to the exciting science of epigenetics. So for conditions that have a genetic basis, an alteration in the genetic material (i.e., DNA) can lead to the condition.”
“The science of epigentics explains why not every gene mutation may lead to expression of the disease/condition. Thus, this may provide an incredible opportunity in medicine to modulate/affect expression of a gene by altering the environment around the chromosome. If one was able to alter expression of a gene in this manner, there would not be a need for genetic engineering that aimed to alter the genetic expression by working on stem cells. Epigenetics has provided insight into the fact that we can alter the genetic expression of an adult cell by altering the environment around it. A very exciting time in genetic science indeed.”
Nicholas A. DiNubile, M.D. Receives Joe Torg Award
The chief of the Section of Orthopedic Surgery at Delaware County Memorial Hospital, Dr. Nicholas A. DiNubile was recently chosen by his peers to receive the “Joe Torg” award at the 14th Annual Philadelphia Sports Medicine Congress. The Torg award is named for sports medicine pioneer Joseph S. Torg, M.D., an orthopedic surgeon at Temple University Hospital. The award honors an orthopedic surgeon in the greater Philadelphia area who has devoted his or her career to the care of athletes, who has participated in the educational process, and who has made significant contributions to the body of knowledge of orthopedics. The award holds special significance because Dr. Torg was Dr. DiNubile’s mentor during his residency at the Hospital of the University of Pennsylvania.
Dr. DiNubile has served as special advisor to the President’s Council on Physical Fitness and Sports (including eight years during the first Bush Administration with Arnold Schwarzenegger as chairman). He also enjoys a strong presence in Philadelphia, where he has served as orthopedic consultant to the Philadelphia 76ers and the Pennsylvania Ballet and has, over the years, cared for members of every Philadelphia professional sports team as well as Olympic athletes.
Knee Replacement and the OTHER Knee
How does the preop functioning of the contralateral knee influence post-knee replacement function? Researchers from Boston University and other institutions have taken a step forward in answering that question. Jessica Maxwell, P.T., D.P.T., O.C.S., is Clinical Assistant Professor, College of Health and Rehabilitation Sciences: Sargent College at Boston University. She and her colleagues, interested in the fact that recent research found a proportion of patients who did not receive a favorable outcome after knee replacement, analyzed data on 271 patients in the Multicenter Osteoarthritis Study who had undergone knee arthroplasty. Dr. Maxwell told OTW, “We found that 27% of 264 patients had poor post-arthroplasty function, and 30% of 250 patients had a slow walking speed. Among subjects with one knee replacement, the higher the pain was in the other knee prior to the surgery, the more likely one would be to have self-reported functional limitations. This was not the case for slow walking speed. Patients in whom both knees had been replaced at the time of outcome collection were less likely to have poor self-reported function than those in whom only one knee had been replaced.
“We were surprised that although the subjects who had both knees replaced reported more ‘acceptable’ function than those with only one knee replaced, that the proportions with slow walking speed were still similar, and were higher. This supports the common notion that self-reported measures and performance based measures do not always demonstrate the same results.”
