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Steroids, 3-D printing among hot topics at AAOS Annual Meeting
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This year’s American Academy of Orthopaedic Surgeons Annual Meeting was held in Orlando, Fla., USA, for the first time in 16 years. As an international member of the American Academy of Orthopaedic Surgeons, I have attended nearly all its meetings since 1988, only missing one or two.
In my younger days as a trainee, I mainly used this meeting for my annual update of knowledge and to identify new treatments for and trends in the management of hip arthroplasty patients. Because this meeting held for me an enormous amount of possibilities for education in a specific subspecialty area, it became my “base” for education. In my senior career, I mainly use the meeting to conduct my professional business with leaders in different areas of orthopaedics because “everybody” shows up at the American Academy of Orthopaedic Surgeons Annual Meeting and you can get meetings organized, decisions made and future plans discussed.
Besides my different business meetings this year, I specifically looked at areas that were new to me, as if I were a young trainee in need of education. I found three areas of particular interest.
Bone cuts with 3-D printing
Top of the list is 3-D printing. Several symposia and free paper sessions were dedicated to this new technology, which involves a digital process that uses a CT scan. The result is a detailed 3-D view of a patient’s bone, which is helpful for devising specific, custom-made implants.
When I returned home after the meeting, a colleague asked me when and if 3-D printing is needed, which may be questions you have as well. My answer is yes, it is needed to improve safety during surgery and the final outcome. I learned about the technique used for larger defects in the acetabulum in adult reconstruction for correction of malformation in the upper and lower extremity — where the printer provides both cutting guides printed to the exact angle at which to cut for optimal correction and provides a custom-printed implant specifically for that bone cut. I also learned how 3-D printing is used to correct malunions of distal radius fractures.
Some may claim they already have the qualifications to do these procedures and corrections without the assistance of 3-D printing. Indeed, many surgeons have such qualifications. However, this technique can result in a safe surgical process and improve the quality of treatments. Although I consider myself an expert in hip surgery, not all of my implants are placed perfectly. I always try to be better at what I do. My only other comment regarding 3-D printing is cost-benefit analyses should be performed before anyone makes a final conclusion regarding this technology.
Steroid injections
My second topic is more a confirmation of what we have learned in recent years about steroid injections in the knee prior to total knee replacement (TKA). It came from a session dedicated to infection as a complication of TKA. Studies now show there is a significantly increased risk of deep infection after TKA when the patient has a steroid injection in the 6 months prior to surgery. The relative increase in deep infection was shown to be 40% to 60% after TKA in these cases, and the risk of infection increased dramatically when TKA was done just a few weeks after the injection. Given that information, I wonder if we should still operate on patients who had a steroid injection in the months prior to a planned TKA.
This can be looked at another way, in terms of consent. Once the surgeon informs the patient about the increased risk of infection, can the patient then still decide in favor of having the surgery immediately? I do not think this decision should be in the patient’s hands. It must be made by the surgeon, and personally, with this new information, I would delay the TKA for at least 9 months to 12 months. We see all too often the bad outcomes of deep infection after TKA, so I would definitely ask for a delay.
Obesity: Worldwide concern
My final observation is also in an area that is not new, but one that represents an increasing problem that needs more attention. Obese patients have significantly more complications than non-obese patients. Worldwide, more patients are obese or morbidly obese based on the BMI scale. In my own department, we see several cases annually in which the patient’s obesity is a problem. We have tried hard to set-up rules about weight loss before surgery and demand patients lose weight even before the possibility of joint replacement can be discussed. Unfortunately, patients rarely substantially reduce their bodyweight. A next step would be possibly asking extremely obese patients to undergo bariatric surgery.
However, new studies have shown that patients who undergo bariatric surgery have malnutrition and often have hypoalbuminemia, to some extent, which can increase the risk of postoperative infection. Given that situation, can we deny these patients the surgery they want and perhaps need? The surgery can be denied because the orthopaedic surgeon is a person who ultimately decides if planned surgery is offered to a given patient. However, very obese patients will never be candidates for joint replacement based on their BMI. I wonder if it is unethical to deny patients joint replacement surgery because of that. So, therein lies the dilemma.
I look forward to discussions in Orthopaedics Today Europe and with my colleagues on these new subject areas and particularly about the steps to take to prepare obese patients for TKA and total hip arthroplasty.
- For more information:
- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Rd., Thorofare, NJ 08086, USA; email: orthopedics@healio.com.
Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.