Residents Predict Medical Apps Will Play Major Role

According to the JBJS 2014 Readership Study, residents are frequent users of mobile medical apps, with 76% saying they have a medical app on their smartphone. Over the next 2 years, residents anticipate that their app usage will become an even greater part of their daily use. According to the study, just over half of residents, 52%, say they expect to rely heavily on mobile apps for obtaining clinical orthopaedic information. Residents place mobile apps 4th out of 8 sources in future reliance, with online journals in first place. Orthopaedic surgeons, on the other hand, rate mobile apps lower in future importance, with roughly a third, 36%, saying they’ll rely on mobile apps the most. For surgeons, online and print journals are at the top of the list.




The True Value of Hip-Fracture Surgery

Currently, each year more than 300,000 Americans sustain a hip fracture, and that number is expected to rise to more than 500,000 within the next 20 to 30 years. A new study– based on a literature review, analysis of Medicare claims, and input from clinical experts–finds that the average lifetime societal from surgery to repair hip fractures reduced the direct medical costs of the surgery by $65,000 per patient. Collectively, that results in an estimated$16 billion lifetime societal savings. These savings include reductions in length of and intensity of postinjury care, and the amount of required long-term medical care and assistance required by surgery patients relative to those whose fractures are treated nonsurgically. The study, published in Clinical Orthopaedics and Related Research, also found that the quality-adjusted life years in people with surgically treated hip fractures increased 2.5 years for patients with intracapsular fractures and 1.9 years for those with extracapsular fractures. To view a summary of the article, read here.

Editor’s Choice—JBJS Reviews, September 2014

It would be an understatement to suggest that the practice of medicine has changed during the past ten years. Indeed, every physician can think of a number of things that have impacted his or her practice. However, among the positive changes that have affected how we treat patients, evidence-based medicine ranks high on the list.

Evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patient values.” Those who support evidence-based medicine note that it will prevent the bias that exists among health-care professionals who frequently base clinical decisions on custom and practice. Hence, the growth of evidence-based medicine along with the desire among clinicians to reduce variations in health-care delivery has had an important and positive impact on health-care practice and policy. Simply stated, the principles of evidence-based medicine serve as a means of decreasing variation in health-care delivery and improving patient outcomes.

The history of evidence-based medicine is interesting and is well covered in the article by David Jevsevar in the September 2014 issue of JBJS Reviews. Concepts and terms are defined, and the findings of research on health-care disparity are discussed. Clearly, the randomized controlled trial (RCT) has become the so-called gold standard in research methodology because of its ability to minimize confounding between patient groups. However, Dr. Jevsevar notes that there are concerns regarding the use of RCTs in the practice of medicine, including their expense as well as the time required for patient recruitment, data analysis, and study completion. As a result of these costs and challenges, most RCTs are now funded by industry, raising concerns about the potential external sources of bias.

This article also touches on other important concepts related to evidence-based medicine in clinical practice policy, such as the propagation and control of conflicts of interest, shared decision-making between physician and patient, and the development of best-practice applications to address the individual needs of and risks to each patient. Finally, it is apparent that the Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010 introduces important and vast changes in access to the U.S. health-care system. Designed to address the unsustainable growth in federal spending and the depletion of the Medicare trust fund that is predicted to occur by 2026, this legislation represents an attempt to “bend the cost curve” by showing the increase in annual health-care expenditures. It further makes the point that the absence of an essentially controlled U.S. health-care system creates a potentially large research laboratory promoting study opportunities to investigate the delivery of high-quality, evidence-based care. Thus, the opportunity for orthopaedic surgeons to become advocates for their patients, to take a leading role in shaping the future of evidence-based medicine, and to do so in a way that generates costs that our nation can afford presents a real opportunity to positively shape the future of orthopaedic practice.

Thomas A. Einhorn, MD, Editor, JBJS Reviews

Editor’s Choice—Essential Surgical Techniques – September 2014

O’Driscoll et al. have included 13 videos in their excellent description of a safety-driven technique for arthroscopic arthroplasty of the elbow. While detailing a four-step process for both the anterior and posterior compartments, in eight of the videos, these authors simultaneously display both the exterior surgical field and the intra-articular arthroscopic view with a “picture-in-picture” format. Viewers can thus see what camera and instrument maneuvers the surgeon is performing to achieve the arthroscopic views and surgical goals. Furthermore, the technique videos are “chaptered” so viewers can easily locate, replay, and study specific details at their leisure.

Edward Y. Cheng, MD, Editor, Essential Surgical Techniques

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves.

The right elbow of a sixty-four-year-old man with hypertrophic osteoarthritis. Posterior and anterior compartment three-dimensional surface-rendering (A, B, C, and D) and two-dimensional sagittal scans (E and F) showing typical osteophytes and non-united fractured osteophytes (black arrow) on the olecranon and a loose body near the capitellum (white arrow). The dotted lines define the osteophytes to be resected (E and F). Particular attention has to be paid to the proximity of the osteophytes to the major nerves. Source: JBJS Essential Surgical Techniques (3/3/e15)

New” but Not Necessarily “Improved”

A review of five hip- and knee-implant innovations, initiated by the FDA in reaction to serious problems with metal-on-metal hip bearings, found that none offered meaningful functional or patient-outcome benefits over older designs. The systematic review of 118 studies and more than 13,000 patients, published in the BMJ, also found that three of the new designs—ceramic-on-ceramic hip bearings, modular femoral necks, and high-flexion knee implants—were associated with higher revision rates relative to established designs. The other two innovations—uncemented monoblock acetabular cups and sex-specific knee implants—provided no benefit over older designs but had comparable revision rates.

The BMJ authors claim that the purpose of the review was not to “criticise the surgical community or orthopaedic industry,” but rather to “highlight that the status quo regarding the introduction of new device technologies is not acceptable.”

The BMJ authors cite stepwise introduction of new implant technologies as one way to avoid exposing large numbers of patients to innovations whose safety and efficacy are unproven. In a 2011 JBJS supplement, authors (two of whom also co-authored the BMJ study) proposed using roentgen stereophotogrammetric analysis (RSA) and national joint registry data to facilitate phased clinical introduction of new implants.

From Sutures to Staples to….Zippers?

The Zip Surgical Skin Closure device from ZipLine Medical (Campbell, CA) is an intriguing recent evolution in surgical wound closure. If the experiences of two orthopaedic surgeons from OrthoIndy in Indianapolis are any indication, this innovative method could be poised for clinical take-off.

Jack Farr, MD and David A. Fisher, MD, (both authors of JBJS-published papers) have observed improved patient satisfaction with Zip, as compared with sutures or staples. In an article they contributed to Orthopedics This Week (subscription required), Drs. Farr and Fisher also tout the theoretical reduction in infection risk, seeing as Zip closes wounds without perforating the skin.

The Zip attaches to the skin adjacent to the incision with a hydrocolloid adhesive. The individual straps for wound tensioning carry the potential to distribute closing forces more evenly than sutures or staples, and “in our experience, applying the Zip took about the same amount of time as applying staples,” Farr and Fisher wrote. The incision remains exposed in the center of the device so absorptive dressings placed on top can collect wound exudates.

Another significant advantage is the increased range of motion that Zip allows due to the device’s “programmed separation” feature, which permits it to lengthen upon joint flexion without stressing the incision. Four days after partial knee replacement surgery closed with Zip, Dr. Farr himself was using a stationary bike. Farr and Fisher also report reduced patient apprehension about removal. Zip is simply peeled off, easing the trepidation that’s often associated with staple removal.

Although the OrthoIndy experience with Zip has been uniformly positive, it has been anecdotal. To bolster the evidence base, Drs. Farr and Fisher (neither of whom reportedly has any financial stake in ZipLine Medical) are planning a prospective randomized, controlled study on “bilateral partial or total knee patients to measure the differences between the Zip and staples.”

Editor’s Choice: Advanced Diagnostics for Carpal Tunnel Syndrome–How Come?

In the Sept. 3, 2014 issue of The Journal Fowler et al. elegantly compare the accuracy of ultrasound for confirming the clinical diagnosis of carpal tunnel syndrome with the current standard of electrodiagnostic testing. In a very well-designed trial using the validated CTS-6 patient-reported outcome tool as the reference standard, they determined 90% diagnostic specificity and 89% sensitivity for ultrasound, with a corresponding 80% specificity and 89% sensitivity for electrodiagnostic testing. In this experimental design, high-volume practitioners administered the diagnostic tests so there is a caveat: the reliability of both ultrasound and electrodiagnostic testing is probably dependent on practitioner experience.

The study clearly shows that in patients with positive CTS-6 results and no signs of radiculopathy or polyneuropathy, ultrasound is as good as electrodiagnostic testing at confirming the diagnosis–and more comfortable for the patient. But the findings also beg a question: Do we really need any adjunctive testing for this group of patients, who I think represent the majority of those presenting with carpal tunnel syndrome symptoms? Wouldn’t the patient-reported symptoms and physical-exam results that are captured in the CTS-6 be sufficient?

I believe most of us agree that a careful history and physical exam should always form the basis for most diagnoses in orthopaedics. Carpal tunnel syndrome has a well-clarified anatomic basis and a very effective surgical treatment. There may occasionally be a role for conservative care but it is often ineffective, and patients should be counseled carefully about the limited efficacy of splints and corticosteroid injections. For most patients in whom this diagnosis is strongly suggested by history and exam, advanced testing is not needed and only adds to patient and system costs. By ordering these tests only for complex cases in which the diagnosis or severity of impairment is unclear, we will be improving patient outcomes while lowering the overall cost of care. That in turn will help us achieve the “triple aim” of access, good outcomes, and lower cost.

Publisher’s Note: Leaving Behind a Stronger Journal and a Stronger Organization

One measure of success for leaders is whether the organization they’ve led is stronger upon their departure. That’s a responsibility I’ve taken seriously for nearly 5 years as CEO/Publisher of STRIATUS/JBJS, Inc.

In the near future, I will be leaving STRIATUS/JBJS, Inc. to become Publisher at the American Association for the Advancement of Science (AAAS), which publishes the journal Science, along with Science: Translational Medicine, Science: Signaling, and Science: Advances.

While I’m sad to leave my colleagues and this audience, I’m happy to report that over the last 5 years, STRIATUS/JBJS, Inc. has improved and grown in a number of ways:

  • This year, The Journal’s impact factor increased nearly 33% to its highest level ever, while The Journal remains the most-read journal in the specialty.
  • Our new review journal, JBJS Reviews, is already one of the top online journal destinations in the field.
  • The new JBJS Recertification Course has proven popular and effective with surgeons preparing for their maintenance-of-certification exams.
  • JBJS Case Connector is improving clinical awareness and acumen on a monthly basis, with “Case Connections” synthesizing old and new information and “Watches & Warnings” alerting the field to emerging trends.
  • With a growing video library, JBJS Essential Surgical Techniques continues to provide in-depth, step-by-step guidance on new surgical techniques, and plans to take practical surgical video to a new level in 2015.

With an excellent editorial team led by our new Editor-in-Chief, Marc Swiontkowski, MD, these journal and educational products are poised for long-term success.

In addition to improving and extending its core products, STRIATUS/JBJS, Inc., has diversified into new areas, adding important tools to the scientific literature, products emphasizing quality evidence and peer review. SocialCite, which allows feedback on the quality and appropriateness of journal citations, has major publishers participating in its pilot phase. PRE-val, which brings increased transparency and accountability to peer review, is also generating significant interest across the sciences.

It has been an honor working with the superb staff and editors at STRIATUS/JBJS, Inc., as well as serving the orthopaedic community – orthopaedic surgeons, physical therapists, physician assistants, and others – over the last 5 years. Thank you.

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:


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