Category Archives: Orthopaedic surgery

General posts in the field of orthopaedics

Loss aversion and the difficulty of stopping surgery

Posted on by
Reply

Loss aversion was introduced by Daniel Kahneman and Amos Tversky. While rooted in economics, the idea captures a fundamental feature of human decision-making across domains. The image is CC from Jim Choate

In orthopaedic trauma, translating evidence into practice is hardest when the evidence tells us to stop operating. Stig Brorson’s excellent review of proximal humerus fractures (the book is open access) illustrates just how difficult surgical de-implementation can be. Multiple randomized trials, most prominently the ProFHER trial, have shown that surgery offers no long-term advantage over non-surgical treatment for most patients. Yet, despite this, surgical rates have remained high, with a growing tendency to replace rather than preserve the joint. This persistent gap between evidence and practice is not primarily explained by ignorance or lack of data. It is better understood through the lens of human decision-making.
Continue reading →

What should we do with the posterior malleolus?

Posted on by
Reply

Hidden treat (CC by
Karon Elliott Edleson

The posterior malleolus has long been viewed as an important determinant of outcome after ankle fractures. Earlier observational studies (Verhage et al. (2016) and van Hoff et al. (2015)) suggested worse long-term results when the fragment was incongruent or displaced, which in turn fueled a trend toward more frequent fixation. Against this background, many of us were eager to see the POSTFIX RCT that put that theory to a test and the results were not what many expected. Continue reading →

Surgery for sacroiliac joint dysfunction, is this a thing?

Posted on by
Reply

A nice surprise article from JBJS on low back pain. The image is CC by Wanderer99.

Low back pain has a history of failed trials supporting surgery (see Brox et al. and Fairbank et al.) and I was therefore thrilled when I encountered Dengler et al.’s randomized controlled trial (RCT) on sacroiliac joint dysfunction. They showed that arthrodesis outperformed conservative management both early and up to two years after surgery. Continue reading →

Collum screw – to parallel or not

Posted on by
Reply
Two bridges

Bridging the knowledge gap in how to operate femoral neck fractures. The image is CC by Nick Mealey.

One of the first surgeries young orthopaedic surgeons learn is the femoral neck fracture fixation with collum screws. A common theme is how to position the screws and as a young surgeon one often believe that everything depends on the screw position, especially if they’re parallel or not. It was therefore quite fun and liberating to read Nyholm et al’s study with the subtitle: “Minimal Effect of Implant Position on Risk of Reoperation” Continue reading →

And I thought we were done with the mid-shaft clavicle….

Posted on by
Reply
Bicycle

Bicycle injuries are by far the most common mechanism of injury for clavicle injuries. The image is CC by Hiroyuki Takeda.

So… just a few days after my previous clavicle post, Ahrens et al released their multi-center study on 300 patients randomized to surgery. They found that operated clavicles have less pain early on, but that after 9 months they perform the same. The study was excellently performed with 20 centers, adequate patient selection, random block permutation for treatment allocation, and reasonable treatment options. Continue reading →

The clavicle fracture – can the madness finally come to an end?

Posted on by
Reply

Finding the right path can be harder than we want to think . The image is CC by Gwenole Camus.

In the early 2000s Nowak et al. [1] shattered the belief that mid-shaft clavicle fractures always healed fine; even after 10 years almost half of the patients had remaining symptoms*. This common injury had also by in others [2] (with shorter follow-ups) been hinted as problematic, and within short we were showered with fancy new implants. After ≥ 7 RCTs [3], [4] on the subjects it seems that these new implants failed do deliver. Can we finally start questioning if surgery is the solution? Continue reading →

Our AI on par with humans?

Posted on by
Reply

The first step in orthopedic deep learning. The image is CC from Pixabay.

We finally published our first article on deep learning (a form of artificial intelligence, AI) in orthopedics! We got standard off-the-shelf neural networks to perform equally well as senior orthopedic surgeons for identifying fractures. This was under the premise that both the network and the surgeons reviewed the same down-scaled images. Nevertheless, this was better than we expected and verifies my belief that deep learning is suitable for analyzing orthopedic radiographs. Continue reading →

ASA as DVT prophylaxis gaining in popularity?

Posted on by
Reply

Keeping the blood flowing is part of core medical knowledge – then why the controversy? The image is CC by Andi Campbell-Jones

In a recent post I noted that there was a dissonance between what I’ve been taught in school and what is actually the case regarding thrombosis prophylaxis after orthopaedic surgery. A new study by Parvizi et. al. looks into different dosages of ASA as a thromboprophylaxis after joint arthroplasties. Coming from a country that has fully embraced LMWH this feels alien… regardless, there seems to be increasing evidence that challenges my point of view. Continue reading →

Chochrane supports restrictive transfusions

Posted on by
Reply
Will Cochrane break through to the blood thirsty colleagues? The image is CC by Gaviota Paseandera.

Will Cochrane break through to the blood thirsty colleagues? The image is CC by Gaviota Paseandera.

I’ve previously written a two posts on blood transfusions from a surgeons perspective (End of the blood reign and A bloody mess) and I was therefore thrilled when I stumbled upon this [Cochrane review](https://www.ncbi.nlm.nih.gov/pubmed/27731885) that concludes:

The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.

Continue reading →