JBJS Case Connector: Celebrating 10 Years  

JBJS is pleased to note that this year marks the 10th anniversary of JBJS Case Connector. Over the past decade, Case Connector has seen rapid growth toward its goal of establishing a sizable inventory of high-quality, peer-reviewed case reports—enriched by a collection of keywords and search functionality that will allow healthcare providers to recognize commonalities between cases, benefit from the experience of their peers, identify trends, and distinguish between truly rare cases and repeated single instances of a larger problem.  

Insight into Case Connector’s journey and mission can be found in a recent editorial by Co-Editors Dr. Tom Bauer and Dr. Ron Lindsey and Editor-in-Chief Dr. Marc Swiontkowski. 

From just over 200 manuscripts submitted from 28 countries in 2011, with 13 articles published that first year, Case Connector received more than 1,000 case report submissions from 54 countries, with 320 articles published, in 2020. Reports have been authored by academic scientists, private practitioners, residents, physical therapists, medical students, and other healthcare professionals.  

JBJS extends its thanks to all who have contributed to Case Connector’s success to date. Authors interested in submitting an article to Case Connector are encouraged to visit the Author Resource Center for additional information and guidance.  

Time Is Running Out…

…to apply for the JBJS Robert Bucholz Journal Club Support Program for the 2021-2022 academic year. Applications are due by September 30, 2021.

Please click here for application information.

Today we heard from Dr. Paula Ramirez, chief resident at the University of Chile’s Department of Orthopaedics and Traumatology. Along with sharing these photos of their first journal club meeting, Dr. Ramirez said, “Thanks again for your support. This pandemic has not been easy for us, but we managed to keep motivated as residents to learn new evidence-based medicine and stay updated. We are definitely applying again this year.”

In Pursuit of Alternative Antibiotics for Use in PMMA Bone Cement

The incorporation of antibiotics within polymethylmethacrylate (PMMA) has been widely used over recent decades for managing infection following skeletal trauma. Early research helped to clarify which antibiotics in which formulations were potentially clinically effective, with a common application of managing “dead space” following debridement of bone and soft tissue, addressing established infection as well as preventing deep infection. As the microbiology involved in these infections evolves, along with the antibiotics available, we have need for continued research into this important area of orthopaedics.

In the September 15, 2021 issue of JBJS, Levack et al. report on their investigation into the suitability of alternative antibiotics (amikacin, meropenem, minocycline, and fosfomycin) for use in PMMA beads,  with a particular focus on thermal stability and in vitro elution characteristics. Tobramycin was also used to validate the study methodology. Minimum inhibitory concentrations of the antibiotics were tested against S. aureus, E. coli, and Acinetobacter baumannii. Antibiotic-laden PMMA beads of different sizes were tested, with antibiotic elution determined using high-performance liquid chromatography with mass spectrometry.

The authors found that amikacin was comparable to tobramycin with respect to heat stability and elution. Meropenem showed favorable elution kinetics and thermal stability in the initial 7 days.

The investigators emphasize that “The data presented are intended to generate further study of these antibiotics to better identify potential areas of clinical utility,” and they rightly point out that their data are not intended for clinical decision-making, “as antibiotic dosages and in vivo applications, specifically with biofilms, have not been evaluated.”  Nonetheless, these new data involving the characteristics of amikacin and meropenem are intriguing. Moreover, this study serves as a great reminder of the need to regularly reevaluate established therapies as research techniques, pharmacology, and clinical conditions (such as evolving microbial pathogens) continue to change.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Spotlight on Recent OrthoJOE Episodes

This guest post comes from David Kovacevic, MD, FAAOS, who provides a summary overview of recent episodes of the OrthoJOE podcast 

The July 2021 OrthoJOE podcasts from JBJS and OrthoEvidence, featuring Mohit Bhandari, MD and Marc Swiontkowski, MD, covered 2 topics of noted interest to orthopaedic surgeons: machine learning and the fragility index (FI).  

Machine learning, a subset of artificial intelligence (AI), is the study of computer algorithms that can improve automatically through experience and the use of data. In OrthoJOE episode 15, “Machine-Learning Algorithms in Orthopaedics,” Drs. Bhandari and Swiontkowski discuss the opportunities and challenges of machine learning in our field. They note a recent study in which the authors aimed to develop machine-learning algorithms that could successfully predict which athletes will achieve clinically meaningful improvement after undergoing primary hip arthroscopy for femoroacetabular impingement syndrome1. Nearly 77% of the athletes achieved the minimally clinically important difference (MCID) for the Hip Outcome Score-Sports Subscale (HOS-SS) at a minimum of 2 years. Six patient covariates were responsible for algorithm performance optimization; there was a consistently decreased likelihood of achieving the MCID if a patient had a:  

  • Preoperative HOS-SS score ≥ 58.3 
  • Alpha angle of ≥ 67.1° 
  • BMI of >26.6 kg/m2 
  • Tönnis angle >9.7° 
  • Tönnis grade of 1
  • Age of >40 years 

The best-performing algorithm was the elastic-net penalized logistic regression (ENPLR) model. More on this study can be found in this previous OrthoBuzz post.   

Among the take-home points outlined in the podcast:  

  • Widespread clinical adoption of this particular machine-learning algorithm will not be possible until it is externally validated, but machine learning nonetheless will help us move the orthopaedic surgery field forward once we take time to understand the principles and learn the nomenclature  
  • At its core, this is a study of prognosis using regression techniques 
  • It is unlikely that AI will replace what we do daily  
  • We need to create datasets that are of high quality, specific to AI and machine-learning algorithms 
  • We must continue to educate one another 

In OrthoJOE episode 16, “The Fragility Index: Why Is It Important to the Practicing Surgeon?,” Drs. Swiontkowski and Bhandari discuss how the FI is a sobering reminder that evidence-based medicine in our surgical field needs more large multicenter clinical trials to answer fundamental questions on improving and optimizing orthopaedic care. Fundamentally, the FI is a statistical measure for evaluating the robustness of the results of a clinical trial with dichotomous outcomes. Or simply put, the FI is a number indicating how many patients would be needed to convert the findings of a trial from statistically significant to nonsignificant. Authors from McMaster University conducted a systematic review to determine the FI in randomized controlled trials related to primary total joint arthroplasty2. A total of 34 RCTs met the inclusion criteria, with a median sample size of 103 patients (range, 24 to 791). Using a Fisher exact test, the median FI was determined to be 1 (range, 0 to 45), indicating that reversing the outcome of only one patient in either treatment group of each study would lead to a change from a significant to nonsignificant result. Compared to previously published studies across numerous orthopaedic subspecialties, the median FI for primary total hip and knee arthroplasty is the lowest2.   

Among the take-home points:  

  • The fragility of RCTs for primary total hip and knee arthroplasty is startling  
  • We may be misleading ourselves if we rely too heavily on small clinical trials to guide our clinical decision-making. Striving toward large multicenter trials may better serve us in answering important questions in orthopaedic surgery  
  • Small trials (i.e., single-center trials with 100 patients) may not provide definitive evidence when fragility of the findings is high 
  • Meta-analysis does not eliminate this issue because of heterogeneity in study design and methodology as well as bias  
  • Evidence-based medicine, from its onset, principally begins and ends with the patient, with the goal of utilizing the best available evidence to inform the patient and the clinician while discussing the risk-to-benefit ratio of a particular treatment strategy 

David Kovacevic, MD, FAAOS, is an orthopaedic surgeon who specializes in shoulder, elbow, and sports medicine surgery. He is also a member of the JBJS Social Media Advisory Board. 

To access other OrthoJOE episodes or to subscribe to the podcast, click here. 


  1. Kunze KN, Polce EM, Clapp I, Nwachukwu BU, Chahla J, Nho SJ. Machine learning algorithms predict functional improvement after hip arthroscopy for femoroacetabular impingement syndrome in athletes. J Bone Joint Surg Am. 2021 Jun; 103(12): 1055-62. doi: 10.2106/JBJS.20.01640.  
  2. Ekhtiari S, Gazendam AM, Nucci NW, Kruse CC, Bhandari M. The fragility of statistically significant findings from randomized controlled trials in hip and knee arthroplasty. J Arthroplasty. 2021 Jun; 36(6): 2211-8. doi: 10.1016/j.arth.2020.12.015. 

Video Summary: Association Between Knee Alignment and Meniscal Tear in Pediatric Patients with Anterior Cruciate Ligament Injury

Delayed ACL reconstruction in patients ≤16 years old with varus-aligned knees might be associated with an increased incidence of secondary medial meniscal tears.

Read the full article here.


Apply Now for JBJS Journal Club Support

JBJS fosters orthopaedic education through multiple activities and platforms, one of which is supporting journal clubs through the Robert Bucholz Resident Journal Club Support Program.

Orthopaedic residents around the world engage in journal clubs to acquire knowledge relevant to clinical practice and to learn how to critically appraise the orthopaedic literature. One recent recipient of journal club support described it as “a huge opportunity for us as a community program without a significant amount of funding from elsewhere.”

This year, for the second time, JBJS is accepting applicants for the Journal Club Support Program from orthopaedic residency programs both inside and outside the United States.

The $1,500 stipend allows residency programs to support their journal clubs in many ways:

  • Investigating new and innovative alternatives to traditional journal clubs
  • Bringing in authors or JBJS editors to discuss articles
  • Hosting a virtual journal club with multiple authors via teleconference or social media
  • Purchasing food and refreshments for journal club meetings

Applications for the 2021-2022 Robert Bucholz Resident Journal Club Support Program are now available and are due by September 30, 2021.

Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons 

The risk of radiation exposure in the operating room (OR) is of increasing interest to orthopaedic surgeons, and the advent of lead vests and aprons, thyroid shields, and lead glasses have given surgeons wearable protection in the OR. However, recent research has demonstrated that lead vests and aprons do not adequately shield the most frequent site of breast cancer, the upper outer quadrant (UOQ) of the breast, which commonly extends into the axilla.

In the September 1, 2021 issue of JBJS, Van Nortwick et al. report on the efficacy of lead vest supplements in reducing breast radiation exposure. The researchers simulated a standard OR setting, placing an anthropomorphic torso phantom, representing a female surgeon, adjacent to an OR table. Dosimeters were employed, and scatter radiation dose equivalents were measured during continuous fluoroscopy of a pelvic phantom, representing the patient. Using 2 C-arm positions (anteroposterior and cross-table lateral projections), and with the surgeon in 2 different positions (facing the table and perpendicular to it), 5 different configurations were tested:

  • No lead
  • Lead vest
  • Lead vest with wings
  • Lead vest with sleeves
  • Lead vest with axillary supplements (the wing placed on the inferior aspect of the axillary opening)

Across scenarios, the average breast UOQ radiation exposure with the use of a lead vest alone (97.4 mrem/hr) did not differ significantly from that with no lead protection (124.1 mrem/hr). However, compared with lead vest alone, significantly less exposure was seen with the use of sleeves (0.8 mrem/hr) and axillary supplements (1.3 mrem/hr). Wings (59.4 mrem/hr) decreased exposure to a lesser extent than sleeves or axillary supplements (and the difference when compared with lead vest alone was not significant). Also noted, C-arm cross-table lateral projection had higher scatter radiation than the anteroposterior projection, as has been demonstrated in previous studies.

The authors point out that, in creating the axillary supplement, a standard wing was simply attached below the axilla rather than above the shoulder, a novel approach to increasing vest protection. While comfort in using lead sleeves or axillary supplements is important to investigate further, data from this study could help inform vendor design modifications resulting in greater protection from breast radiation exposure, and ideally eliminate the need for surgeons to have to “MacGyver” a solution from existing parts.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

A downloadable JBJS infographic summarizing this study can be found here.



Press Ganey Survey in Ambulatory Upper-Extremity Care: Assessing Nonresponse Bias  

Patient surveys are now being widely used by hospital systems to monitor patient satisfaction with the process of inpatient and outpatient musculoskeletal care. While data from the surveys can help guide quality-improvement efforts, many clinicians have some concerns with the survey results in that the patients who respond may not be representative of all patients, and patient-care experiences may differ between survey “responders” and “nonresponders.” 

In the September 1, 2021 issue of JBJS, Weir et al. delve further into this topic in their report on the response rate and factors associated with the completion of the Press Ganey Ambulatory Surgery Survey (PGAS) among patients treated with upper-extremity procedures in their outpatient surgical center. Of the 1,489 included patients, only 13.5% (201 patients) responded to the survey. The authors found significant differences between the responder and nonresponder groups with respect to baseline characteristics, including race (72% vs 57% White in the 2 groups, respectively), education (49% vs 40% with a college degree), employment status (88% vs 79% employed), income (49% vs 34% with income ≥$70,000), and marital status (54% vs 43% currently married).  The responders also had better pre-intervention PROMIS scores across multiple domains, although the authors note that these differences were not clinically meaningful.  

While emphasizing that factors influencing response rates are multifactorial and complex, the authors state that “The existence of substantial differences between responders and nonresponders raises concern for potential nonresponse bias for the PGAS.” They further point out that “surgical centers may be disproportionately missing the experiences of minority groups with lower socioeconomic status, and more focused efforts may be needed to ensure that these patients have equitable care experiences.”  

It seems to me that avenues toward increasing the collection of patient responses might include improved processes for following up with nonresponders using personalized phone calls or emails, or potentially other incentives to collect these data. Survey vendors themselves have a role to play, working with hospital systems to enhance the credibility of these commonly utilized tools. With more inclusive response, providers are likely to be more confident in applying survey feedback to the practice environment, thereby improving the process of care for our patients.  

Marc Swiontkowski, MD
JBJS Editor-in-Chief