Decent Work/Life Balance Found in Ortho Residencies

Doximity’s 2015-2016 Residency Navigator is designed to help medical students make informed choices about residency programs by analyzing more than 94,000 ratings and hand-written reviews from Doximity members who are currently in or recently graduated from US residency programs. From that data, Doximity’s VP of Product Management Shari Buck turned up two interesting findings about orthopaedists in training:

–Among the specialties with the highest ratings for work hours (tolerability of shift and call schedules) and schedule flexibility (real-life accommodations for events such as weddings and pregnancy), orthopaedic surgery came in fourth, behind physiatry, dermatology, and radiation oncology—and just ahead of emergency medicine.

–On the other hand, female residents in general appear to be less satisfied than their male counterparts, and the gender gap is especially pronounced in historically male-dominated specialties like orthopaedic surgery (83.7 percent satisfaction among women versus 95.9 percent for men; p<0.05).

Case Connector “Watch” Cites Trunnion Troubles in Modular Hip Implants

The hip-arthroplasty community currently feels that the advantages gained from head-neck modularity outweigh the risks, but JBJS Case Connector raises that risk-benefit question in an August 26, 2015 “Watch” article. Modular head-neck failures of total-hip prostheses are indeed rare complications, but the potentially catastrophic consequences and a seemingly increased incidence are raising concern among orthopaedists.

Prompted by a case report by Swann et al. in the August 26, 2015 JBJS Case Connector and a report by Arvinte et al. in the April 22, 2015 JBJS Case Connector, the Watch describes three patients who experienced a complete head-neck dissociation seven to fourteen years after primary arthroplasty with modular components. The Watch also includes relevant findings from elsewhere in the orthopaedic literature to help surgeons better understand and minimize the risks.

The trunnion troubles described in this Watch represent a unique opportunity for orthopaedists and industry to work together to conduct multicenter retrieval studies to better understand, and prevent, these rare but serious outcomes. In the meantime, the Watch ends with the following message: “Absent ‘official’ protocols for monitoring THA patients with new-generation modular head-neck junctions, it would behoove hip surgeons to inform patients about these rare events and to encourage them to report any postoperative abnormalities, even if the signs or symptoms are not painful.”

What’s New in Orthopaedic Trauma: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the July 15, 2015 Specialty Update on orthopaedic trauma:

Clavicular Fractures

–Among 46 patients with acute clavicular fractures, upright radiographs were better than supine radiographs at demonstrating clavicular displacement.

Proximal Humeral Fractures

–A prospective randomized study of 120 patients undergoing open reduction and internal fixation (ORIF) of proximal humeral fractures showed that the deltoid-split and deltopectoral approaches resulted in similar patient outcomes.

Femoral Shaft Fractures

–Multiple studies investigating femoral rotation after treatment with intramedullary rods found that, other than increasing comminution, no patient, injury, or surgical variables increased the risk for malrotation.

–Use of electromagnetic targeting for placing femoral-rod locking bolts decreased radiation exposure and may decrease surgical time when using retrograde rods.

Distal Femoral Fractures

–Proximal fixation with far cortical locking screws to dynamize bridge-plate fixation was safe and produced better healing than did standard locking implants investigated in previous studies.

Tibial Plateau Fractures

–Ten years after surgery for displaced tibial plateau fractures, 7.3% of 8426 patients needed a total knee arthroplasty, a 5.3-fold increase relative to the general population’s need for knee arthroplasty.

–Among 40 patients with surgically treated intra-articular tibial plateau fractures, the use of continuous passive motion immediately after surgery did not provide lasting range-of-motion or other clinical benefits.

Distal Tibial Fractures

–A prospective randomized trial of 142 patients found that the use of angular stable locking screws with intramedullary nailing did not improve short-term outcomes relative to the use of conventional locking screws.

Calcaneal Fractures

–A post hoc analysis of 8- to 12-year results from a randomized trial of 56 patients demonstrated better long-term outcomes among those who were treated operatively versus nonoperatively.

–Among 31 patients randomized to undergo either ORIF or ORIF with primary subtalar fusion, researchers found no functional differences, although ORIF with primary fusion may provide quicker healing and prevents the need for late secondary fusion.

Mental Health Issues

–Among a prospective cohort of 152 patients treated operatively for one or more fractures, psychological challenges were highly prevalent, with catastrophic thinking associated with worse mid-term outcomes.

–In a prospective cohort study of 110 patients admitted with orthopaedic injuries, researchers found persistent depression to be associated with higher depression-screening scores and prior psychiatric history.

Infection Management

–In a prospective cohort study of 737 open fractures, injury severity—not time to surgery—was associated with deep infection.

JBJS Reviews Editor’s Choice–Limb Lengthening: Scientific and Clinical Aspects

Bone is one of the most biologically unique tissues in the human body. What distinguishes bone from most other tissues is that, when injured, it heals by regeneration of its original tissue as opposed to the formation of scar. Recognizing this phenomenon, surgeons as early as the turn of the nineteenth century initiated efforts to lengthen limbs by performing osteotomies and initiating distraction immediately. They had various degrees of success. By the middle of the twentieth century, this technique had been refined thanks to the pioneering work of Dr. Gavril Ilizarov, who recognized the importance of a latency period and the rate and rhythm of the distraction. Ilizarov devoted his life to the research and advancement of a minimally invasive procedure that could be used to treat limb-length deformities and injuries by stimulating the formation of new bone. While Ilizarov and others continued to refine these techniques for clinical use, clinician-scientists recognized that the ability to regenerate tissue through slow, steady, and rhythmic distraction at the site of an osteotomy could yield substantial new knowledge in the field of bone repair and regeneration. Following this recognition, experimental studies demonstrated that the process of distraction osteogenesis is driven by the formation of new blood vessels; thus, angiogenesis precedes osteogenesis.

In the August 2015 issue of JBJS Reviews, Compton et al. discuss the potential biological basis for the phenomenon of distraction osteogenesis and recognize the importance of angiogenesis. Vascular endothelial growth factor (VEGF) has been shown to be one of the most essential and important growth factors in the development of bone regeneration and is regulated by its upstream promoter, hypoxia-inducible factor-1 alpha (HIF-1-α). Further research is needed to fully understand the role of specific molecules and genetic mechanisms in the development of regenerate bone.

In another article in the August 2015 JBJS Reviews, Christopher Iobst notes that limb lengthening as a technique has many advantages, yet the surgeon needs to be vigilant about potential lengthening complications such as joint contractures, joint subluxation, and fractures. While an exciting field, the primary goal of limb lengthening is to produce healthy regenerate bone of the desired length without these complications. In addition, the experience should be as easy and comfortable as possible for the patient. A comprehensive and accurate assessment of limb deformities is essential for successful treatment. In order to accomplish this goal, the concept of preparatory operative treatment has been introduced. Such treatment involves preparing the limb for lengthening by first stabilizing the adjacent joints and removing known soft-tissue constraints. Soft-tissue constraints such as the iliotibial band also may need to be addressed at the time of lengthening. Similar preparation has been outlined prior to lengthening in patients with fibular hemimelia. This stepwise and comprehensive approach is vital to the success of the lengthening.

Iobst also explains how patient selection for limb lengthening is extremely important. Lengthening can be a long and stressful process, and a preoperative assessment of the patient’s psychosocial situation is recommended before the lengthening is started. Advances in limb lengthening techniques involving combinations of external and internal fixation and internal fixation alone with intramedullary rods are presented. Completely internal lengthening nails may have potential advantages over combinations with external fixation, including elimination of pin-track infections and a lower risk of neurovascular injury.

These two articles addressing the scientific and clinical aspects of limb lengthening offer a comprehensive review of this fascinating and important topic. I hope you enjoy reading them!

Thomas A. Einhorn, MD

Editor, JBJS Reviews

Fibrin No Friend of Fracture Repair

Researchers at Vanderbilt University Medical Center have concluded that fibrin, a protein involved in blood clotting and found abundantly around the site of new bone fractures, impedes rather than supports fracture healing.

Their recent study in The Journal of Clinical Investigation looked at mice that had experimentally induced deficits in either fibrin production or fibrin clearance. Researchers found normal fracture repair in mice without fibrin and impaired vascularization and fracture healing in mice with inhibited fibrin clearance. They also saw increased heterotopic ossification in the mice unable to remove fibrin.

In a Vanderbilt press release, study coauthor Jonathan Schoenecker, MD, commented that “any condition associated with vascular disease and thrombosis will impair fracture healing.”  These findings, he suggested, may explain why obesity, diabetes, smoking, and old age—all of which are associated with impaired fibrin clearance—are also associated with impaired fracture healing. Dr. Schoenecker went on to speculate that anti-clotting drugs commonly used to treat cardiovascular conditions may find new applications in enhancing fracture repair.

Perioperative Tunes Ease Patient Pain and Anxiety

Providing patients with an opportunity to listen to music during advanced imaging such as MRI scans is well accepted. Now, according to a recent Lancet systematic review/meta-analysis, it may be time to extend that same opportunity to surgical patients. In the Lancet study, patients who listened to music around the time of surgery were found to experience less postoperative pain, analgesia use, and anxiety. Although the choice and timing of music had little difference on outcomes, there was a trend toward greater benefits from listening to music before surgery.

Each of the 73 randomized trials included in the analysis compared the use of music before, during, and/or after surgery with other non-drug interventions such as white noise or bed rest. While only four of the studies focused on orthopaedic procedures, the authors claimed that the preponderance of data shows “that music should be available to all patients undergoing operative procedures.”

The authors attempted to compensate for the heterogeneity of the combined data by performing a random-effects meta-analysis, but they conceded that a single, large randomized trial would be the best way to address heterogeneity when studying the effects of music on surgical patients.

Endoscopic Gluteus Medius Repair Delivers Good Results

Patients who experience persistent hip pain after nonoperative treatments for partial or full-thickness gluteus medius tears have two surgical repair options: open or endoscopic. A two-year follow up study by Chandrasekaran et al. in the August 19, 2015 edition of The Journal of Bone & Joint Surgery found that endoscopic repair with correction of identified intra-articular pathology yielded substantial postprocedure functional improvements and pain reduction, along with high levels of overall patient satisfaction. In addition, 15 of the 26 patients who had preoperative gait deviations were found to have a completely normal gait at the two-year follow up. No postoperative complications or re-tears were reported.

The study followed 34 patients (predominantly women, mean age of 57 years) who had endoscopic repairs. Seventeen (50%) of the patients with full-thickness or near full-thickness tears were treated with a suture bridge technique, while the 17 with partial-thickness tears received a transtendinous repair. There was no significant difference in patient-reported outcome measures between the two surgical techniques.

The ability to address intra-articular pathology is touted as an advantage of the endoscopic approach, and in this study concomitant procedures included capsule release, labral debridement and repair, and acetabuloplasty.

Although the Chandrasekaran et al. study did not compare outcomes of endoscopic versus open repair, it did track the largest reported number of endoscopy patients for the longest reported duration.

JBJS Editor’s Choice—Patient Pain: A Hurdle for All Orthopaedists

Evswiontkowski marc colorery clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8.  I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?

We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al.  identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.

I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.

Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

Did you know that JBJS is an accredited CME provider?

For over 125 years, the Journal of Bone & Joint Surgery (JBJS) has been the premier journal for orthopaedic surgeons. Today, our publication portfolio has grown to 4 peer-reviewed, evidence-based journals. Two of these journals offer continuing medication education (CME) for orthopaedic generalists, specialists and allied health personnel. The development of the CME activities is overseen by a committee consisting of editors from The Journal and JBJS Reviews.

The JBJS CME program is designed to enhance the knowledge, competence and performance of orthopaedic surgeons worldwide, and to improve musculoskeletal health for their patients. Our CME program addresses a range of clinical topics including: adult hip and knee reconstruction, foot and ankle surgery, spine surgery, shoulder and elbow surgery, pain management, sports medicine, pediatrics, and trauma. After successful completion of the period of Provisional Accreditation, JBJS received full accreditation for our CME program in March of 2015.

The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Journal of Bone & Joint Surgery offers two CME activities: The Quarterly CME Activity and the Subspecialty CME Activity. Each of these CME activities is an interactive educational experience of examination questions based on articles published in the Journal of Bone & Joint Surgery. The Quarterly CME Activity contains 50 questions and is also designated for a maximum of 10 AMA PRA Category 1 Credits™. The Subspecialty CME activity contains 10 questions and is designated for a maximum of 5 AMA PRA Category 1 Credits™.

The Quarterly CME activity is approved by the American Board of Orthopaedic Surgery (ABOS) as a Self-Assessment Examination (SAE) that qualifies for SAE CME under the Board’s Maintenance of Certification (MOC) Program. Each Quarterly activity grants 5 SAE credits and must be submitted in pairs for maintenance of certification

JBJS Reviews, our newest journal, offers a journal-based CME activity with each article. Each article contains 5 CME assessment questions that can be completed and submitted after reading the article for 1 AMA PRA Category 1 Credit™.

JBJS is committed to providing timely, relevant CME to orthopaedic surgeons and allied health providers worldwide, promoting effective decision-making and clinical practice based on the gold-standard of peer-reviewed, scientific information contained within our publications.

You can access JBJS CME activities by visiting the JBJS Orthopaedic Education Center.

JBJS Classics: Anterior Acromioplasty for Chronic Shoulder Impingement

JBJS-Classics-logoEach month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

For a good long while, the 1972 JBJS article titled “Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder” by Charles S. Neer II completely changed the treatment approach for patients with shoulder disability. Impingement of the rotator cuff beneath the coracoacromial arch was recognized at that time as the cause of chronic shoulder disability, and complete acromionectomy and lateral acromionectomy at various levels had been advocated for the condition. However, disappointment with the results, such as postoperative deltoid weakness, stimulated Neer to publish this study, based on his experiences with patients from 1965 to1970.  The paper describes relevant anatomical findings and then discusses the indications, technique, and preliminary results of anterior acromioplasty.

Neer first dissected 100 cadaveric scapulae from donors who had been in their sixth decade or older at the time of death,  and he noted spurs and excrescences on the undersurface along the anterior-inferior rim of the acromion in many shoulders  that also had rotator cuff derangement. Without exception, the anterior lip and undersurface of the anterior third of the acromion were involved. He concluded that this part of the acromion rubbed against the supraspinatus when the arm was abducted and caused the rotator cuff to tear over time.

Neer later resected this part of the acromion in fifty shoulders in forty-six patients. When he reexamined twenty-nine of the shoulders between nine months and five years after surgery, he found symptomatic relief in a large percentage of patients. A recent PubMed search identified 471 publications about acromioplasty, the majority of which reference this paper and 50 of which specifically mention Neer by name. Neer’s basic surgical principles are still followed, although this surgery today is performed arthroscopically.

Neer reserved this surgical procedure for patients with long-term disability from chronic bursitis and partial tears of the supraspinatus tendon, or those with complete tears of the supraspinatus associated with tears of varying degree of the adjacent rotator cuff. He emphasized that patients with incomplete tears should not have surgery until the stiffness of the shoulder resolved, and the disability had to persist for at least nine months before surgery was performed. Many patients not included in his series were suspected of having impingement but responded well to conservative treatment.

Neer’s anatomical approach to the challenge of chronic shoulder pain provides readers with photographs of cadaveric shoulders combined with drawings illustrating the pathogenesis and the surgical procedure.  Neer described the results well and in a subsequent discussion concluded that “it is a rare cuff tear that cannot be repaired through this simple approach.” The paper lacked a control group and a detailed description of the rehabilitation protocol, but these shortcomings have been remedied by more recent published research.

Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.

Lars Engebretsen, MD, PhD

JBJS Deputy Editor

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