New Findings in Muscle Injury—An Under-Researched Subject

Periostin for OBuzzThe goal of orthopaedic surgery is to help the entire musculoskeletal system function in harmony, but the preponderance of orthopaedic research focuses on the skeletal system instead of muscles and tendons. Bone is the only organ that can heal by regenerating tissue that is usually just as effective as the original structure. Consequently, we have focused on developing systems to hold bone intact as it heals so that postinjury function is maximized. Decades have been spent understanding the critical biologic pathways of bone healing and developing implantable, pharmacologic, and cell-based therapies to optimize it.

However, we sometimes overlook the fact that the skeleton can’t move without muscles. Only a few researchers have devoted their careers to understanding skeletal muscle’s response to injury and approaches to enhance muscle recovery after disuse and injury. In the August 15, 2018 issue of The Journal, Hara et al. report on experiments with the protein periostin in mice. Periostin is involved with the process of muscle fibrosis, during which fibroblasts proliferate in the injured area of the muscle and create “scar tissue” that eventually inhibits muscle function.

In one experiment, the authors found that “knockout” mice without the gene that encodes for periostin had improved recovery in a lacerated gastrocnemius muscle, less fibrosis in the muscle, and a significantly reduced number of infiltrating fibroblasts than “wild” mice with the same induced injury. In a similar experiment, they found reduced muscle fibrosis in injured muscles of mice whose production of periostin was neutralized by an antibody injected into the injured muscle. Although a sharp injury to muscle (the laceration model used in these mouse experiments) is not a common clinical scenario in patients seen by orthopaedists, the Hara et al. study represents a step forward in understanding muscle response to injury.

While these findings need to be replicated and then translated into clinical applications for humans, they shed new light on the importance of preventing periostin-induced fibroblast migration after skeletal muscle injury. This research hints at a potential therapeutic strategy to enhance muscle’s functional recovery, which is the most sought-after outcome for patients.

The clinical sports and orthopaedic communities are in need of approaches to limit scarring and atrophy in the setting of muscle disuse and injury. Any of us who unavoidably injure muscle during surgical approaches to bones and joints or for graft harvests and other procedures should be heartened by these findings. It is my hope that more early-career researchers will focus on the first half of the term “musculoskeletal” to advance therapeutic approaches to problems that impact function to a much more permanent degree than do most bone injuries.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS 100: Harris Hip Score, Clavicle Fractures

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original full-text content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures—Treatment by Mold Arthroplasty: An End-Result Study Using a New Method of Result Evaluation
W H Harris: JBJS, 1969 June; 51 (4): 737
The most lasting legacy from this classic 1969 article from William Harris is the author’s proposed hip score. A “single, reliable figure” designed to be equally applicable to different hip problems and different treatments, the Harris Hip Score is still used worldwide today in routine evaluations before and after hip arthroplasty. Not surprisingly, this article remains the most frequently cited paper in the hip arthroplasty literature.

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures
Canadian Orthopaedic Trauma Society: JBJS, 2007 January; 89 (1): 1
Amid the ongoing debate about whether to operate on which type of clavicle fractures, this multicenter, randomized clinical trial stands out for its rigorous design and focus on patient-oriented outcomes. Local irritation and unsightly prominence from hardware notwithstanding, these findings support primary plate fixation of completely displaced midshaft clavicle fractures in active adult patients.

New Frontiers in Journal Clubs

Journal Club for OBuzzDepending on which historical account you read, journal clubs have been a staple of medical education since around 1875.  Still ubiquitous within medical education today, journal clubs help educators and students alike stay current on medical literature, provide a vehicle for teaching how to critically appraise medical studies, and convene a forum in which respectful debate can occur among colleagues.  Journal clubs constitute a medical-education practice that almost no one questions, probably because they are so effective.

But that doesn’t mean journal clubs can’t be improved. As the September 30, 2018 deadline approaches to submit applications for the JBJS Robert Bucholz Journal Club Grant Program (click here for the application form), I encourage medical-education leaders to envision new ways in which journal clubs could further orthopaedic education. That might include various iterations of “virtual” journal clubs over the internet. For example, the Journal of Hand Surgery recently hosted a journal club on Twitter.  Another intriguing possibility would be to invite authors of journal articles with conflicting conclusions about the same research question to discuss their findings in a point/counterpoint format over teleconference. (Today’s teleconferencing platforms are not hard to set up, are relatively low-cost, and could broaden journal-club participation to anyone with a suitable device and a high-speed internet connection.)

The traditional face-to-face journal club provides many unique benefits, but creating new, innovative platforms for using departmental or grant-based journal-club funds could increase their impact and help ensure the sustainability of these educational programs. It will also be important for everyone to share their experiences with alternative journal-club formats. It behooves the orthopaedic community to continually envision how to integrate the journal-club component of medical education into new technologies as they evolve.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Cross-Linked Polyethylene for Total Hip Arthroplasty Markedly Reduces Revision Surgery at 16 Years

Total hip arthroplasty (THA) is an effective operation for the management of end-stage hip osteoarthritis, but long-term success can be limited by wear of the polyethylene bearing surface.

Full article: https://bit.ly/2nlQxoL

JBJS.IG.17.01221.ig

Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization

Recurrent anterior instability following a failed Bankart repair in the shoulder represents a challenging clinical scenario.

Full article: https://bit.ly/2M4Xxp0

JBJS.IG.17.01028.ig

JBJS 100: Bankart Repair, Carpal Tunnel Assessment

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

The Bankart Procedure: A Long-Term End-Result Study
C R Rowe, D Patel, W W Southmayd: JBJS, 1978 January; 60 (1): 1
This was the first large clinical series with long follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent or good, and this study contributed to the demise of nonanatomic shoulder repairs.

A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome
D W Levine, B P Simmons, M J Koris, L H Daltroy, G G Hohl, A H Fossel, J N Katz: JBJS, 1993 January; 75 (11): 1585
Distinguishing interventions that work from those that don’t requires rigorous outcomes research, which, in turn, relies on standardized, patient-centered measures that have proven reliability and validity. Meeting these criteria are the Symptom Severity and Functional Status Scales for carpal tunnel syndrome described in this oft-cited JBJS study from 25 years ago.

Sept. 11 Webinar – Assessment of Bone Health for the Orthopaedic Surgeon

Sept Webinar Speakers

Orthopaedic care teams can play an active role in evaluating and optimizing their patients’ bone health to help prevent primary and secondary fragility fractures and to improve postsurgical outcomes. In just about any orthopaedic scenario, helping patients optimize their bone health is an imperative for the delivery of quality care.

On Tuesday, September 11, 2018 at 8 pm EDTthe American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar that will cover the basics of a bone-health assessment by orthopaedists.

  • Christopher Shuhart, MD will discuss the fundamentals of bone-related laboratory workups and bone densitometry studies.
  • Joe Lane, MD, FAOA will identify bone-health “red flags” in orthopaedic patients, including common nutritional deficiencies.
  • Paul Anderson, MD, FAOA will cover recent advances in bone-density measurements.

Moderated by Douglas Lundy, MD, MBA, FAOA, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.

Seats are limited so REGISTER NOW.

Opioid-Tapering Plan May Help Prevent Prolonged Use after Trauma/Surgery

Hydrocodone Has Dark Side as Recreational DrugAddressing the opioid epidemic requires a concerted effort from all sectors of society, but the role of surgeons (orthopaedic and otherwise) cannot be ignored because they determine how best to manage postoperative pain for millions of patients. OrthoBuzz recently commented on two opioid-related studies from the July 18, 2018 issue of JBJS. In the August 1, 2018 edition of The Journal, Mohamadi et al. explain findings from a meta-analysis of 37 studies involving nearly 2 million patients that pinpoint several patient-related risk factors associated with opioid use beyond 2 months following surgery or trauma.

Using careful meta-analysis methods, the authors determined that about 4% of patients continued to use prescription opioids beyond 2 months after surgery or trauma. They also identified the following risk factors as being “among the most important predictors of prolonged opioid use” in these patients:

  • Prior use of opioids or benzodiazepines
  • Depression
  • Long-duration hospital stay
  • History of back pain

Mohamadi et al. also calculated a “number needed to harm” (NNH) from their data. NNH indicates the number of patients with a certain risk factor that is necessary to result in 1 person with prolonged opioid use beyond that of a patient population without that risk factor. They found that for every 3 patients with a history of opioid use, every 23 patients with a history of back pain, every 40 with depression, or every 62 with a history of benzodiazepine use, 1 patient will continue to use prescribed opioids for an extended time period.

Because this meta-analysis was derived from observational studies, the authors caution that “causal inferences could not be drawn for the proposed risk factors.” But they do offer a practical piece of advice gleaned from prior research: Provide patients with an opioid-tapering plan at the time of discharge to significantly reduce the likelihood of prolonged opioid use.

August 2018 Article Exchange with JOSPT

jospt_article_exchange_logo1In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of August 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.”

The authors’ findings confirmed their hypothesis that robust risk adjustment is essential for objective comparison of patient-reported outcomes and for accurately reflecting quality of care among patients treated for low back pain.

New Patient-Outcomes Data Hint at Benefits from Computer-Navigated TKA

computer navigation knee for OBuzzLike the vast majority of orthopaedic surgeons, I do not use computer navigation for total knee arthroplasties (TKAs). My hospital does not own the equipment, I have not asked for it, and I feel confident in the outcomes for my patients using current conventional techniques. Moreover, we have not had published data suggesting that using computerized navigation actually improves the one thing we care most about: patient outcomes.  However, the two-year data presented by Petursson et al. in the August 1, 2018 issue of JBJS may represent a tipping point.

The authors report on 2-year results from a double-blind, prospective randomized trial evaluating outcomes in 167 patients following TKAs performed using conventional techniques or computer-guided navigation. Both patients and observing radiologists/physical therapists were blinded to the technique used.

Among the many patient-reported measures used to compare 2-year outcomes, the authors found that scores for 3 subscales favored the computer-navigation group. Specifically, the symptom and sports-and-recreation subscales of the KOOS and the stiffness subscale of the WOMAC showed significantly greater improvements in the group that underwent computer-navigated TKA. These results led Petursson et al. to conclude that TKAs completed with the assistance of computer navigation provided better pain relief and function at two years postoperatively.

These are important findings, as this is one of the largest randomized, double-blind analyses comparing computer navigation versus conventional TKA. While previous studies had found computer navigation to be useful in terms of obtaining neutral mechanical alignment, data showing improved patient outcomes was either lacking or revealed no clinically important between-group differences.  These 2-year data suggest that this is no longer the case.  However, it is important to note that the study does not explicitly state whether patients were still blinded to their treatment at the time when the 2-year follow-up data was collected.  If they were no longer blinded at that point of follow-up, the results would need to be viewed from a more tempered perspective.

Either way, it is important to note that in this study—as in previous research investigating similar questions—TKAs completed using conventional techniques also yielded large improvements in patient-reported outcomes. Still, because patients and surgeons alike continue to be intrigued by the possibilities that technological advances in arthroplasty may offer, studies like this are vital.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media