JBJS 100: Epiphyseal Plate Injuries, Spinal Osteomyelitis
Under 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:
Injuries Involving the Epiphyseal Plate
RB Salter, WR Harris: JBJS, 1963 April; 45 (3): 587
In addition to presenting the fracture classification, the authors laid the groundwork with basic principles of mechanical failure and vascularity of the physis. The authors then explain how physeal damage may arise from misalignment, crushing, or vascular interruption. This enduring orthopaedic schema lives on because of its clarity of presentation and its implications for treatment.
Pyogenic Osteomyelitis of the Spine
J Kulowski: JBJS, 1936 April; 18 (2): 343
In this 22-page analysis and discussion of 102 cases, the author notes that pyogenic osteomyelitis of the spine can affect any part of the vertebral system. In 1936—8 years after the discovery of penicillin—Kulowski said, “It may be axiomatically stated that operative intervention is imperative, as soon as the diagnosis is made with a reasonable degree of accuracy, when suppuration is present…,” adding that “the primary spinal focus requires the first attention of the surgeon.”
October 2018 Article Exchange with JOSPT
In 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 October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.”
This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.
Team Physicians Finally Get Federal Licensing and Liability Protection
When it comes to passing federal legislation on Capitol Hill, common-sense solutions for relatively straightforward problems are often not easy to come by. There always seems to be something holding up every piece of legislation, no matter how great the benefits and how minimal the risks/costs.
That is why I was happy to hear that Congress passed the Sports Medicine Licensure Clarity Act earlier this month. The legislation clarifies that health care services provided by a licensed provider in a state other than the one in which he/she is licensed (a scenario commonly encountered by physicians and athletic trainers who travel with collegiate or professional athletic teams) will be considered in-state services and will be covered by the provider’s liability insurance.
The American Association of Orthopaedic Surgeons (AAOS) and several other provider groups—including the American Orthopaedic Society for Sports Medicine (AOSSM)—have long recognized that previous laws exposed many team physicians to medical liability if they provided care in states in which they did not have a medical license. The Clarity Act protects orthopaedic surgeons, athletic trainers, and other health care professionals who serve as traveling care providers from licensure hassles and potential liability so they can focus on caring for their athlete-patients.
As someone who has been engaged in orthopaedic advocacy efforts for my entire, albeit short, orthopaedic career, I am proud of this accomplishment. Advocacy is not for the faint of heart, and the amount of work that goes on behind the scenes to get legislation like this enacted is astounding. Arguably, such efforts have never been more important than they are in today’s health care environment. If we, as orthopaedic surgeons, do not advocate on behalf of our patients and ourselves, no one else will.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Cost Analysis of Treatments for Unicompartmental Knee Arthritis: UKA Wins
Surgical treatment for knee osteoarthritis (OA) has become increasingly common. The many people who have damage to only one part of their joint (unicompartmental knee OA) are faced with three options—total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or nonsurgical treatment. A study by Kazarian et al. in the October 3, 2018 issue of The Journal estimates the lifetime cost-effectiveness for those three options in patients from 40 to 90 years of age.
The authors used sophisticated computer modeling to estimate both direct costs (those related to medical/surgical care) and indirect costs (such as missed workdays) of the three options as a function of patient age at the time of treatment initiation. Here are the key findings:
- The surgical treatments were less expensive and provided patients from 40 to 69 years of age with a greater number of quality-adjusted life years (QALYs) than nonsurgical treatment.
- In patients 70 to 90 years of age, surgical treatments were still cost-effective compared with nonsurgical treatment, albeit less so than in younger patients. In this older age group, “cost-effectiveness ratios” of surgical treatment remained below a “willingness to-pay” threshold of $50,000 per QALY.
- When the two surgical treatments were compared to one another, UKA beat TKA decisively in cost-effectiveness among patients of any age.
After crunching more numbers, Kazarian et al. estimated that, by 2020, if all of the patients with unicompartmental knee OA who were candidates for UKA or TKA (a projected total of 120,000 to 210,000 people) received UKA, “it would lead to a lifetime cost savings of $987 million to $1.5 billion.
From these findings, the authors conclude that patients with unicompartmental knee OA should receive surgical treatment, preferably UKA, instead of nonsurgical treatment until the age of 70 years. After that age, all three options are reasonable from a cost-effectiveness perspective.
But perhaps the most important thing to remember about these findings is that they add information to—but should not replace—clinical decision-making based on complete and open communication between doctor and patient.
New Isn’t Always Better
Diagnosing acute compartment syndrome (ACS) is challenging. The signs and symptoms of ACS are easy to conflate with those of the overall musculoskeletal injury; the treatment, fasciotomy, is not without risks; and the consequences of delaying or missing the diagnosis altogether can be catastrophic. It is for these reasons that the notion of a device that can continuously monitor a wounded extremity for ACS and alert surgeons when intervention should be considered is so appealing. Yet, as the study by Schmidt et al. and the METRC group in the October 3, 2018 JBJS suggests, the ideal and reality are not aligned.
In this prospective blinded study, the authors evaluated the ability of near-infrared spectroscopy (NIRS) sensors and intramuscular pressure (IMP) catheters to monitor the tissue oxygen-saturation and compartment pressures, respectively, of patients who sustained an injury that is associated with the development of compartment syndrome. They found that clinically useful NIRS data was available only about 9% of the time, whereas IMP information was available >85% of the time. Certain injury characteristics (such as fractures associated with hematomas) made obtaining data with the NIRS especially difficult.
While these results don’t bode well for NIRS as a reliable ACS monitoring tool, it should be noted that the users of the NIRS system in the study were mostly unaware of when the NIRS system was not collecting clinically useful data in real time. Obviously, you can’t correct a problem if you don’t know it exists, and it is possible the results of the study would have been different if NIRS users were able to troubleshoot the system when data were not being captured. Still, after reading this article, it seems difficult to justify using NIRS to monitor a patient for development of ACS.
New diagnostic tools and techniques are always being developed, and we should remember the results of this study when any “new-fangled” device enters the clinical landscape. A test’s most important feature is its ability to reliably provide clinically useful data to aid in decision-making. If it cannot do so, it is simply providing distracting ”noise” from which misinterpretations can be made.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Activities that Patients—and their PTs—Should Avoid After THA
The adult joint-reconstruction community has made great strides in the last 2 decades in understanding what causes aseptic loosening of arthroplasty components. For example, revelations about polyethylene particulate debris has led to the production of highly cross-linked polyethylene, which in turn has lowered wear rates, decreased revision rates, and increased the survivorship of total hip implants (see related OrthoBuzz post). Still, polyethylene debris is only one factor that can lead to aseptic loosening. Another important, yet often overlooked, factor is friction between the impacted acetabular shell and the host bone.
In the October 3, 2018 issue of The Journal, Bergmann et al. report data that help us better understand the “friction factor” in aseptic loosening. The authors implanted specially designed, instrumented acetabular components that measured in vivo friction moments among nine patients while they engaged in >1,400 different activities. The authors found that 124 of those activities led to friction moments >4 Nm—which appears to be the upper limit for facilitating a firm union between the acetabular component and the native socket.
Movements such as muscle stretching in the lunge position, the breaststroke in swimming, 2-legged standing with muscles contracted, and a single-legged stance while moving the contralateral leg were among those that created the highest friction between the implant and the host bone—and that could impede bone ingrowth into the acetabular component and thus contribute to aseptic loosening. The study also highlights the importance of periodic unloading of the prosthetic joint to allow proper synovial lubrication, which helps minimize the effects of high-friction moments. The good news is that the vast majority of activities studied do not appear to result in friction forces above the 4 Nm threshold.
Although these data should be confirmed with other in-vivo instrumented prostheses (assuming there are more patients willing to receive acetabular components capable of delivering telemetric data), they provide practical insight into the real-world forces placed on total hip prostheses after implantation. Such information can be used to counsel patients regarding high-friction and sustained-loading activities to be avoided, and it can help physical therapists and surgeons tailor postoperative regimens that optimize patient recovery while minimizing the risk to implanted prostheses.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS 100: Approach to the Lumbar Spine, Knee Flexion Contracture
Under 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:
The Paraspinal Sacrospinalis-Splitting Approach to the Lumbar Spine
LL Wiltse, JG Bateman, RH Hutchinson, WE Nelson: JBJS, 1968 July; 50 (5): 919
In this classic 1968 JBJS paper, Wiltse and co-authors described a novel and innovative access route to the lumbar spine. Advantages included reduced blood loss, less muscle ischemia, and the preservation of spinous processes and intra-/supraspinous ligaments. The Wiltse approach still represents one of the main access routes to the lumbar spine.
Treatment of Knee Flexion Contracture Due to Central Nervous System Disorders in Adults
JN Martin, R Vialle, P Denormandie, G Sorriaux, H Gad, I Harding, O Dizien, T Judet: JBJS, 2006 April; 88 (4): 840
To address what was at the time a lack of interest among orthopaedic surgeons in treating spasticity in adults, these authors expanded upon earlier work studying the treatment of knee flexion contractures in this population. Their procedure included distal hamstring lengthening, a posterior capsulotomy in some of the knees, and use of a unilateral external fixator in most of the knees. Mean flexion contracture improved from a mean of 69° preoperatively to a mean of 6.2° at 1 to 5 years after surgery.
Diversity in Orthopaedics: Taking Action to Drive Change – Nov. 14 Webinar
On Wednesday, November 14, 2018 at 8:00 PM EST,the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
- Lisa Lattanza, MD, FAOA
For a very personal take on diversity in orthopaedics, read the “What’s Important” article by Joseph Zuckerman, MD from the August 1, 2018 issue of JBJS.
Seats are limited, so REGISTER NOW.
Influence of Physical Activity Level on Total Knee Arthroplasty Expectations, Satisfaction, and Outcomes
Background: Patients undergoing total knee arthroplasty expect pain relief, functional improvement, and a return to physical activity. The objective of this study was to determine the impact of patients’ baseline physical activity level on preoperative expectations, postoperative satisfaction, and clinical outcomes in patients undergoing total knee arthroplasty.
Botulinum Toxin Type A Versus Placebo for Idiopathic Clubfoot
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