First 3D-Printed Cervical Disc Implanted

For any number of reasons, regulatory issues among them, orthopaedic innovations in China often have modest relevance for the practice of orthopaedics elsewhere in the world, but that doesn’t make them any less fascinating.

Case in point: According to Becker’s Spine Review, surgeons in China recently implanted the first-ever 3D-printed cervical disc in a 12-year-old boy. The surgeon, Dr. Liu Zhongjun, described the procedure as successful, although the patient will have to remain in a head frame with pins for three months.

The Becker’s story did not specify the material from which the cervical disc was printed, but 3D printing is capable of producing porous metal implants, and companies have reported success with 3D-printed implants made from thermoplastic materials.

One theoretical advantage of 3D-printed orthopaedic implants is that they can be customized based on digital images of a patient’s actual anatomy. That would conceivably result in a better fit, quicker recovery, and fewer complications.

Still, don’t expect to find a 3D prosthetic printer in your hospital anytime soon. Clinical studies required to ensure the safe and effective use of even the most promising new technologies take years. And even after such studies are completed, regulatory approval and coverage from payers is not guaranteed.

Value of Orthopaedics; A Major Focus in Washington

In May, more than 300 orthopaedic surgeons attended the National Orthopaedic Leadership Conference in Washington, DC. During the conference, attendees took time to recognize the success of the AAOS Project Value initiative, which was started by former AAOS president John R. Tongue, MD. The initiative’s project team set out to quantify the social and economic benefits of musculoskeletal health care.

Four studies have been published as a result of this effort, three of which were published in JBJS:

AAOS also hosts a website to highlight the notion of value in orthopaedics: www.ANationInMotion.org/value.

Low-Paid, Debt-Ridden Residents Still Optimistic

Despite an average resident salary of $55,330 a year and over a third (36%) claiming they owe more than $200K in loans when they finish residency, 83% of residents polled by Medscape said they are still looking forward to practicing as a physician. Medscape’s recent survey, Residents Salary & Debt Report 2014, polled 1,200 residents across 25 specialties and revealed that orthopaedic residents make an average annual salary of $57,000. The highest average resident salaries of $65,000 are in critical care, and the lowest ($52,000) are in family medicine.

Despite low salaries, heavy debt load, and long work hours 66% of Year 1 residents spend 60+ hours a week at work. Roughly half (48%) of male residents and 60% of female residents said they are compensated fairly.

Gender influences salaries in resident programs, but the male/female differential is only 4%, much lower than the 24% difference by gender among non-resident physicians. Geography also makes a difference in resident pay. Residents in the Northwest receive the highest salary (an average of $71K) followed by those in the Northeast, with an average salary of $61K.

Editor’s Choice—JBJS Reviews, August 2014

“Prothesenlockerung PET-CT” by Hg6996 – Own work. Licensed under Creative Commons Attribution-Share Alike 3.0-2.5-2.0-1.0 via Wikimedia Commons

The treatment of periprosthetic infection remains one of the most difficult and challenging problems in orthopaedic surgery. Conventional approaches such as the use of tissue and/or fluid cultures to identify and treat organisms are not nearly as successful as they need to be in order to address these conditions. The limitations of treatment, including the inaccessibility of microorganisms at the time of irrigation and debridement, the development of resistant strains of microorganisms, and the elaboration by microorganisms of protective biofilms, have led to unsuccessful outcomes in a large number of cases.

In this issue of JBJS Reviews, Chen and Parvizi provide an update on some of the new methods that may possibly advance this field. Molecular methods such as polymerase chain reaction to amplify bacteria can improve the likelihood of identifying the pathogen in a patient with a periprosthetic joint infection. Synovial markers such as C-reactive protein, leukocyte esterase, α-defensin, human β-defensin-2 (HBD-2) and HBD-3, and cathelicidin LL-37 are known to be elevated in patients with periprosthetic joint infection and may be used as markers for diagnosing infection at the time of operative management. Serum markers such as interleukin-4 (IL-4) and IL-6, and others such as soluble intracellular adhesion molecule-1 (sICAM-1) and procalcitonin (PCT), have been shown to be elevated in patients with periprosthetic joint infection.

Molecular detection methods probably have received the most attention and interest as an advancement that may improve our ability to diagnose periprosthetic infections. The limitations of these methods, however, include their high sensitivity and an increased rate of false-positive results. Methods to reduce the number of false-positive results are currently in development and include, among other things, the measurement of 16S ribosomal RNA in the belief that targeting RNA will result in amplification of only the genetic material of live bacteria. In addition, use of the mecA gene for identifying methicillin-resistant Staphylococcus aureus (MRSA) can reduce this rate.

Although this article does not provide definitive new approaches to the problem, the review of recent advances with the development of promising biomarkers and molecular techniques provides optimism that this field is evolving in a positive way.

Rotator Cuff Repair—Does Healing Matter: A JBJS Webinar

What’s more important after rotator cuff repair: How the shoulder feels and functions or how it looks on an MRI or ultrasound?

Rotator cuff disease is the most common cause of shoulder pain and dysfunction.  Operative repair is frequently performed with successful outcomes.

However, postoperative imaging studies reveal structural failures after such repairs in up to 90% of patients. The good news: many of those patients experience pain relief and improved function despite “failure.”

Two JBJS papers that shed new light on this and other rotator-cuff conundrums are the foci of this timely and insightful JBJS webinar:

Factors Affecting Outcome After Structural Failure of Repaired Rotator Cuff Repairs

Structural Integrity After Rotator Cuff Repair Does Not Correlate with Patient Function and Pain

Moderated by Andrew Green, MD, JBJS Deputy Editor for the Upper Extremity, this webinar will conclude with a live Q&A session, during which the audience can query the authors and commentators—and get answers—in real time.

Webinar attendees will hear from study authors Michael Khazzam, MD, and Jay D. Keener, MD. In addition, rotator cuff experts Scott Rodeo, MD, and Robert Tashjian, MD, will further analyze the findings from these studies and add perspectives from their own experience and research.

Register now to learn from this panel of experts and contribute to the dialogue—all from the convenience of your computer, smartphone, or tablet.

Register here for the Sept 22 webinar:

Moderator: Andrew Green, MD

Presenting authors: Jay D. Keener, MD, and Michael S. Khazzam, MD

Commentators: Scott Rodeo, MD, and Robert Tashjian, MD

Sponsored by:

Modernizing Medicine

Aspirin’s Effectiveness in VTE Prevention Varies by Procedure

“Deep vein thrombosis of the right leg” by James Heilman, MD – Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons

A recent meta-analysis of eight randomized trials (1,408 total patients) compared aspirin to anticoagulants such as warfarin and dabigatran for preventing venous thromboembolism (VTE) after hip and knee arthroplasty and hip-fracture repair. The analysis found that the overall prophylactic power of these two medical approaches was essentially equal following major lower-extremity surgery. However, the comparison, appearing in the Journal of Hospital Medicine, found a slightly higher (but statistically nonsignificant) risk of deep vein thrombosis (DVT) with aspirin following hip-fracture repair. Conversely, the risk of bleeding after hip-fracture surgery was lower with aspirin than with anticoagulants.

For additional insight into VTE prophylaxis, view the FREE recorded JBJS webinar “Preventing Arthroplasty-Associated Venous Thromboembolism.” Register here.

Shoulder Impingement: Steroid Shots and PT Equally Effective

People with shoulder impingement syndrome (SIS) randomly assigned to six sessions of physical therapy (PT) experienced the same 50% improvement in average pain and disability scores as a similar group that received up to three corticosteroid injections over the course of a year. However, the injection group made more office visits and had more additional procedures during the 12-month follow-up period.

Editorialists commenting on this Annals of Internal Medicine study hypothesize that the lower resource utilization of the PT group may be attributed to patient-clinician interactions that “provide an opportunity for therapists to better address patients’ concerns about their conditions, provide reassurance, or educate patients in self-management.” They go on to say that if further research pinpoints specific inflammatory and non-inflammatory “diagnostic phenotypes” of SIS patients, clinicians could prescribe more targeted therapies.

Interstate Licensing Reform Effort Progressing

The Federation of State Medical Boards recently unveiled an updated draft of its “interstate compact” for physician licensure. Because physician licensing is a state-by-state process, once the compact language is finalized, states would have to approve participation legislatively.

The compact would offer a streamlined process for licensing physicians to practice in more than one state. The potential benefits include providing physician services in rural and underserved areas and promoting the growth of telemedicine.

Eligibility for expedited licensing will be limited to board-certified physicians with an unrestricted license in one state for the past three years, and to those who’ve had no run-ins with disciplinary boards, courts, or the DEA. The physician would be responsible for paying required fees to the additional states and to the interstate commission overseeing the process. The location of the patient, not the physician, would be the jurisdiction for oversight, and participating state boards would be required to share complaint and investigative information with other participating states.

The federation expects legislation to be ready for states to consider beginning in early 2015, and federation president Humayun Chaudhry, DO, expressed confidence that the compact would be endorsed by all states. In the meantime, stakeholders will have to address questions such as how patient insurance and medical liability insurance will work with the compact.

Editor’s Choice: “Doc, What Would You Do if This Was Your Knee?”

Many orthopaedic surgeons come from an active background, often including competitive sports and other “high energy” activities. Injury is no stranger to many of us. In fact, it is often a youthful injury that put us in contact with an orthopaedic surgeon and spurred us to consider a career as a physician. Once we gain exposure to the various specialties in medical school rotations, we often find that orthopaedic surgeons are the most contented lot and have abundant enthusiasm for their patient-care activities… and we join the tribe.

Knee injury is common to many sporting activities, and of the various types of knee injuries, ACL rupture is among the most common. Many orthopaedists have experienced it firsthand. During my surgical education, ACL repair was in its infancy and we were navigating the transition between extra-articular and intra-articular reconstruction. Early in my academic career, I could identify many colleagues who had an ACL tear (diagnosed by physical exam with perhaps an arthrogram to check for meniscal tears, in those days prior to MRI) who had not undergone surgical reconstruction. This was my own personal situation. Now that the diagnosis is highly reliable and highly reproducible outpatient arthroscopic reconstruction is available, I suspect this is no longer the case. However, for patients who have lower functional expectations and demands in their future, nonoperative treatment should still be an option.

In the August 6, 2014 JBJS, Grindem et al. do the orthopaedic community a huge service by providing data from a prospectively enrolled and carefully followed cohort of 143 patients with ACL rupture who were treated both operatively and non-operatively. This study design carries all the limitations associated with any cohort study, with selection bias being a big factor. The findings that the 100 patients who selected reconstruction were younger and had expectations of higher-level sport activity are not surprising. This same surgically treated cohort was more likely to experience knee re-injury, probably due to increased exposure from level-I sports. The 43 nonsurgical patients returned to level-II sports in the first year much more quickly and in the second year were more likely to return to level-III sports than their surgically treated counterparts. In essence, there were no major differences between the two populations at two years in terms of knee extensor and flexor weakness. Those findings are no doubt highly correlated to patient factors such as rehabilitation compliance.

I conclude that there is still a role for non-operative management of ACL rupture in patients who select this route during a shared decision making process. We know that there seems to be a higher risk of subsequent meniscal injury in people without an ACL, but many patients are willing to accept this risk.

Donald Fithian tells us what he thinks of this study in an accompanying JBJS commentary. What do you think?

A Conversation with Vern Tolo, MD

Tolo_Vernon_1791Vernon Tolo, MD, JBJS Editor-in-Chief Emeritus, provided outstanding editorial stewardship for The Journal during the last four years. In this interview, he explains what the experience has meant to him.

JBJS: As you transition out of the role of Editor-in-Chief at JBJS, what will you miss the most?

Dr. Tolo: There are a few things I will miss. One is the opportunity to work with a great group of Deputy Editors, whose work is essential and so important to the Editor. I will miss the JBJS staff, who are all talented professionals and who provided great support to me during my time as Editor.  And I will miss seeing the latest in research reports, often months before publication occurs.  The time I spent as Editor were some of the most exciting and rewarding years of my orthopaedic career… a true privilege to be able to carry forward the tradition of JBJS.  Nonetheless, I will not miss the relentless assignment of manuscripts which required nightly connection to my computer….but I still had a great time.

JBJS: When you first joined JBJS, what surprised you the most about The Journal or about journal publishing in general?

Dr. Tolo: I had known primarily about the editorial side of journal publishing from my years being a JBJS Deputy Editor. What surprised me the most when I became Editor was how little I knew about trends in medical publishing and the challenges facing journals such as JBJS in today’s publishing world. Being involved in meeting these challenges has stimulated me to think about problems and challenges that I otherwise would not have considered.

JBJS: As JBJS celebrates its 125th anniversary this year, how would you describe the impact of The Journal on orthopaedics?

Dr. Tolo: The Journal has had a tremendous impact on orthopaedics. For the first 100 years, JBJS was the primary written source of orthopaedic education for all orthopaedic surgeons in North America. Articles published in JBJS were the source of a large percentage of questions in the Board examinations for years.  Even after the explosion of educational sources in the past 25 years, The Journal still holds a pre-eminent position for quality, trusted research reports that affect day-to-day patient care.

JBJS: How do you think JBJS can best support orthopaedics going forward?

Dr. Tolo: We need to continue to be the trusted source for new orthopaedic knowledge that improves patient care. The multiple journals that the JBJS family has developed over the past few years have really broadened the choices available to orthopaedists, as has the option for webinars throughout the year.

JBJS: What trends in orthopaedics are you most intrigued by?

Dr. Tolo: I am not sure “intrigued” is the right word, but I am concerned about the ongoing tendency for super-specialization within our profession. Despite having exposure to and training for the treatment of a wide variety of orthopaedic conditions during residency, orthopaedists are increasingly claiming they are inadequately trained to treat a wide variety of orthopaedic conditions, particularly once they have completed a fellowship in a subspecialty. For example, pediatric orthopaedists may feel uncomfortable treating hand or pelvic fractures. Sports medicine orthopaedists will often not get involved with treatments outside their fellowship training.  And it goes on with many other examples.  This situation only seems to be increasing.  The ongoing challenge is how to adjust training programs to allow for appropriate broad-based training opportunities and still allow residents to focus on the subspecialty in which they will eventually practice.

The trend over the past several years of orthopaedics being a specialty selected by more medical students than there are residency openings will likely continue.  We are still the most underrepresented surgical specialty for women in training programs and on faculties.  While some progress has been made in this area, we need to increase the number of women in orthopaedics.

JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?

Dr. Tolo: The changes in orthopaedics have been so dramatic in the past 20 years that it is a challenge for me to predict how our profession will look in 2034. I think medical schools will finally include education in musculoskeletal disorders commensurate with the percentage of patients with these conditions who are seen by primary care physicians. Robotic surgery, currently so common in surgical specialties that deal with soft tissue disorders, may soon be ready for orthopaedic use, but that will be a decade or more from now.  Biologics will be used more often, particularly in settings to decrease the onset of articular cartilage damage after ACL injury or intraarticular fractures, and this would be a major advance.  It may be that a “bone glue” may supplant casts as a fracture treatment.  Whatever advances occur, JBJS is where they should be published.

JBJS: What is your favorite thing about your profession?

Dr. Tolo: No question….it is helping patients get better. I am fortunate to have worked in pediatric orthopaedics my entire career. All children want to get better, and the ability to play a part in helping advance the health of children has been extremely rewarding for me.  I still love going to work every day, and the grateful feedback that I receive almost daily from families is incredible. There are few other professions or vocations that provide this benefit.

JBJS: What are you looking forward to most as you make this transition?

Dr. Tolo: Once I have dealt with my withdrawal symptoms from my time at JBJS, I will increase my clinical outpatient and operative activity at the Children’s Hospital Los Angeles, mainly in spinal deformity, skeletal dysplasia, and cerebral palsy, though probably a bit less than 100% full time. I look forward to spending quality time with my wife Charlene, who has put up with a sometimes crazy schedule for 49 years of marriage, and to getting my golf handicap down to the low teens.  It will be difficult for me to break away completely from orthopaedics, which has provided me with an incredibly satisfying career and multiple opportunities to contribute to our profession globally, through a number of societies/associations–and through JBJS.

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