Baylor University basketball star Isaiah Austin was 20 years old when the NBA told him last month that he had Marfan syndrome and was ineligible to play professional basketball. Why was Austin not diagnosed with this potentially fatal connective-tissue disorder earlier in life? The answer may lie in a 2010 study by Sponseller et al. in JBJS. The authors point out that early diagnosis of Marfan syndrome is complicated by the fact that many of its recognizable skeletal features—including scoliosis and flat feet—appear with some frequency in the general population.
By studying people with confirmed Marfan syndrome and those without, the authors discovered that the most diagnostically relevant physical characteristics of the syndrome are craniofacial features such as narrow cranial shape and positive thumb and wrist signs. The combined presence of those characteristics yielded an area-under-the-curve diagnostic accuracy of 0.997. Doctors often recommend that people with suspected Marfan syndrome receive confirmatory genetic tests, which are readily available but expensive.
Even though it’s difficult to recognize Marfan syndrome on the basis of physical observation alone, Sponseller et al. suggest that orthopaedists “at least briefly visualize the entire patient” and consider a referral for genetic testing and/or echocardiogram when the aforementioned features are present.
For his part, Mr. Austin took the news in stride. He said he plans to return to Baylor to finish his degree and perhaps become a Marfan syndrome advocate-educator. His inspiring Instagram message: “Please do not take the privilege of playing sports or anything for granted.”
When physical therapy or anti-inflammatory medication fails, one popular treatment for leg pain caused by spinal stenosis is a steroid injection. However, according to a recently published , that treatment may be less effective than previously thought. The study found that patients with painful lumbar stenosis who received a combined lidocaine-glucocorticoid injection had about the same pain levels and degree of disability six weeks later than similar patients who were injected with lidocaine alone.
While these findings question the presumed efficacy of adding a glucocorticoid to lidocaine for epidural injection, they do not necessarily mean that all epidural injections for spinal stenosis are ineffective.
NEJM abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1313265
According to the orthopaedic surgeon edition of Kantar Media’s Website Usage & Qualitative Evaluation study, JBJS.org ranks hands down as the #1 orthopaedic site that surgeons visit most often and spend the most time on. The Kantar study evaluates the opinions of orthopaedic surgeons on 29 professional websites, including 8 orthopaedic sites. Not only does JBJS.org rank number 1 among the other 7 orthopaedic sites in frequency of visits (4.7 times/month), the website ranks first among all 28 sites evaluated in terms of time per session (20.31 minutes). Additionally, JBJS.org ranks #1 in delivering quality clinical content and keeping surgeons informed of the latest practices and procedures. JBJS ties for first place in the category of information on drugs, devices, or professional services. Also noteworthy is the fact that JBJS Reviews, a new online review journal from JBJS launched in November 2013, has already taken over third place in time spent and number of site visits.
JBJS Webinar Series
JBJS has held multiple live webinar events on a wide variety of topics, and we are pleased to announce the expansion of the JBJS Webinar Series in 2014. Each webinar has proven to be a successful tool in educating, informing and engaging orthopaedic surgeons around the world. In 2014, JBJS is continuing this educational program through a new series of interactive online events.
Our webinars bring together groups of authors to present recently published scientific research and data, and they include commentary from guest experts. Live Q&A sessions follow the author and commentator presentations to provide the audience with the opportunity to further explore the concepts and data presented. Webinars continue to be available on-demand for several months after the event.
AVAILABLE ON-DEMAND (Previously Recorded Events)
Total Knee Arthroplasty Critical Decision Making: Socioeconomic and Clinical Considerations (June 10, 2014) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Thomas S. Thornhill, MD
Commentators: Daniel J. Berry, MD and Kevin Garvey, MD
Preventing Arthroplasty-Associated Venous Thromboembolism (VTE) (May 12, 2014) – Moderated by Thomas A. Einhorn, MD
Panelists/Authors: Clifford W. Colwell Jr, MD and John T. Schousboe, MD
Commentators: Vincent Pellegrini Jr, MD and Jay Lieberman, MD
Anterior Cruciate Ligament (ACL) Reconstruction (March 5, 2014) – Moderated by Mark Miller, MD
Panelists/Authors: Freddie Fu, MD and Christopher Kaeding, MD
Commentators: Brett Owens, MD and Darren L. Johnson, MD
Adhesive Capsulitis/Frozen Shoulder (December 2013) – Moderated by Andrew Green, MD
Presented in conjunction with the Journal of Orthopaedic & Sports Physical Therapy.
Panelists/Authors: George Murrell, MD, Martin J. Kelley, DPT, Jo Hannafin, MD, PhD, and Philip W. McClure, PT, PhD
Periprosthetic Joint Infection (October 2013) – Moderated by Charles R. Clark, MD
Panelists/Authors: Kevin J. Bozic, MD and Craig J. Della Valle, MD
Commentators: Javad Parvizi, MD, FRCS, and Geoffrey Tsaras, MD, MPH
Measuring Value in Orthopaedic Surgery (September 2013) – Moderated by James Herndon, MD
Panelist/Author: Kevin J. Bozic, MD
Commentators: David Jevsevar, MD and Jon J.P. Warner, MD
Editor, JBJS Reviews: Thomas A. Einhorn, MD
According to a recent JBJS readership study among 1,000+ orthopaedic surgeons and residents, sources used for obtaining clinical orthopaedic information vary depending on one’s resident or surgeon status. For example, 9 out of 10 residents rely heavily on online journals, compared to 8 out of 10 surgeons. The reliance gap between online and print journals is much more significant among residents (94% to 68%) compared to the gap among surgeons (80% to 77%). Mobile app usage is much more common among residents, with just more than half, 52%, using them heavily for clinical orthopaedic information, compared to 36% among surgeons. As the graph shows, two other significant differences between residents and surgeons are the use of textbooks and social media sites as sources of clinical information.
…And a Geography Gap:
Surgeons outside the US and Canada are more dependent on online journals for their clinical orthopaedic information than surgeons in North America (91% international to 77% US/Canada). Textbook usage also varies greatly by geography. Within the US and Canada, only 28% of surgeons rely heavily on textbooks, while close to 60% of international surgeons rate text books high in usage. Twice the percentage of international surgeons rely heavily on social media for clinical information, compared to those within the US/Canada (5% vs. 13%).
This is my first Editor’s Choice for OrthoBuzz as new Editor-in-Chief of JBJS. I am following the example of my esteemed predecessor, Vern Tolo, who recently issued an Editor’s Choice warning about our failure to improve the management of patients with fragility fractures in terms of appropriate diagnosis and treatment of underlying osteoporosis. That is a failure of under-treatment. I want to focus on a potential issue of overtreatment.
In the July 2, 2014 JBJS, Leroux et al. describe the risk factors for repeat surgery after ORIF of midshaft clavicle fractures. The study analyzed 1,350 patients treated with surgery between 2002 and 2010 in Ontario. It is important to note that this analysis includes years after 2007, when JBJS published the seminal multicenter RCT on this topic by the Canadian Orthopaedic Trauma Society (COTS). The essence of that study was that ORIF with plate fixation results in a lower rate of nonunion and better functional outcomes predominantly in patients who have completely displaced fractures with about 2 cm of shortening or displacement.
Since that publication, we have seen an explosion in the operative treatment of midshaft clavicle fractures in North America. However, all too often the inclusion criteria derived from the seminal RCT are not referenced in individual patient decision making, and the presence of a clavicle fracture–regardless of degree of displacement–becomes an indication for surgical management.
The findings of the Leroux study should help put a hard stop to this! These researchers found a 24.6% incidence of repeat surgery in this cohort of patients. The most common reoperation was isolated implant removal (18.8%), and the incidence of major complications included nonunion (2.6%), deep infection (2.6%), pneumothoraces (1.2%), and malunion (1.1%). Risk of reoperation was increased in female patients and in those with major medical comorbidities. Limited surgeon experience increased the risk of reoperation for infection.
The orthopaedic surgery community must heed these data and act upon them. We should not misinterpret the COTS study to “encourage” a patient to opt for surgery if he or she has a midshaft clavicle fracture with less than 2 cm of shortening or displacement. The technical aspects of surgery for midshaft clavicle nonunion is not that different than that for a fresh fracture, so avoidance of nonunion must be thoughtfully discussed with the patient before recommending surgical fixation.
The bottom line that Leroux et al. provide is that surgery for a midshaft clavicle fracture is not a guaranteed success and that surgeon experience matters. And beyond clavicle fractures, let’s be sure we use our literature during shared decision making in an accurate and appropriate manner. That is a basic tenet of professionalism that we all should subscribe to.
In a comprehensive 43-page document freely available in Clinical Infectious Diseases, the Infectious Diseases Society of America has updated its guidelines for diagnosing and managing skin and soft-tissue infections. Of special interest to orthopaedic surgeons, the guidelines include an algorithm for simpler analysis and treatment of surgical-site infections and updated approaches to treating localized purulent infections in light of concern about drug-resistant strains of Staphylococcus aureus.
Some pediatricians have been hesitant to prescribe fluoroquinolone antibiotics such as levofloxacin for children because animal studies have found a risk of cartilage injury. A 5-year follow-up safety study of levofloxacin published recently in Pediatrics compared the safety of levofloxacin with a comparator antibiotic in more than 200 children. The number of musculoskeletal adverse events that were “possibly” related to the drugs was very low and essentially the same in both groups. This led the researchers to conclude that “the risks of cartilage injury with levofloxacin appear to be uncommon, are clinically undetectable during 5 years, or are reversible.” In a NEJM Journal Watch commentary on the study, Deborah Lehman, MD said these findings provide at most “a lack of endorsement of the fluoroquinolone-associated musculoskeletal problems seen in preclinical studies.” She adds that the study was limited by the fact that only half of the patients completed the planned 5-year follow up.
The venographic prevalence of deep vein thrombosis in people with distal lower-extremity injuries that require surgery or casting ranges from 10% to 40%. But a prospective cohort study in the May 21, 2014 JBJS found that only 0.6% of 1200 patients with lower-leg fractures and no medical or mechanical thromboprophylaxis had symptomatic, objectively confirmed venous thromboembolism (VTE) over a 12-week follow-up. Moreover, none of the seven thrombotic complications was fatal. This leads the authors to conclude that “the risk-benefit ratio and cost effectiveness of routine anticoagulant prophylaxis are unlikely to be favorable for these patients.” They go on to say that despite the large sample size in this study, the low prevalence of VTE made it impossible to pinpoint characteristics that could identify a subgroup of similar patients who might be at higher risk of clotting problems.
Many practices are investing in expensive EMR systems while overlooking simpler ways of lowering costs and increasing efficiencies. According to Jay Crawford, MD, pediatric and adolescent specialist at Knoxville Orthopaedic Clinic, optimizing patient scheduling is one of many simple improvements that could maximize practice revenue. Crawford has developed a new mobile app and cloud-based solution that helps redirect patients who don’t need to be seen by an orthopaedic surgeon, increases brandawareness for a private practice, and drives efficiencies.
Dr. Crawford’s custom mobile app, NextDocVisit.com, helps increase revenue per patient by identifying patients whose level of injury does not warrant a visit to an orthopaedic surgeon. Patients benefit also because after entering their information through the app, they get a message letting them know when they can expect a call back. Dr. Crawford estimates this type of system can weed out low-revenuepatients and potentially increase revenues by 1 to 2%. Dr. Crawford is currently building custom scheduling apps for two other practices. He concludes, “Changes coming to our industry are so significant that you must change how you do business in order to survive. That’s a hard thing to make people understand.”
According to a recent JBJS readership study among more than 1,000 orthopaedic surgeons, print readership of JBJS remained fairly consistent from 2012 to 2014; 91% accessed the JBJS print edition frequently/occasionally in 2012, and 87% did so in 2014. The percentage of respondents accessing JBJS online access jumped significantly from 58% in 2012 to 74% in 2014. Roughly 30% cited reading all/most of their issue in both the 2012 and 2014 studies.
Additionally, the survey revealed a slight increase in relevancy of JBJS to clinical practice/research compared to 5 years ago. In 2012, 33% stated JBJS was more relevant compared to the past 5 years; in 2014 36% rated JBJS more clinically relevant that it was 5 years prior.