Association ≠ Causation: Are Steroid Injections for OA Risky?

A recent report in Radiology citing possible complications from injecting steroids into painful joints with osteoarthritis (OA) has received lots of attention in the mainstream media. Radiologists from Boston, Germany, and France reviewed the existing literature and found an association between intra-articular steroid injections and a small increased risk of four adverse joint findings: accelerated OA progression, subchondral insufficiency fracture, complications from osteonecrosis, and bone loss. However, the study did not include a control group that did not receive injections, and therefore it cannot be used to assess whether injections are associated causally with the adverse joint findings.

In an interview with Boston radio station WBUR, lead author Ali Guermazi, MD stressed the point that readers should not conclude from this report that steroid injections cause these complications, adding that additional research in this area is “urgently needed.” In the same radio coverage, Jeffrey Katz, MD, a professor of orthopaedic surgery at Boston’s Brigham & Women’s Hospital and a Deputy Editor at JBJS, said patients who have received such injections or plan to should not be overly worried. However, he added that “for clinicians and patients who’ve been doing injections for several years, it’s worth it to pause and say, ‘Do we want to discuss [again] what we think are the benefits and risks of this.’”

Elite Reviewer Spotlight: Kodali Siva Prasad

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Kodali Siva Rama Krishna Prasad

Affiliation: Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, Mid-Glamorgan, Wales, United Kingdom.

Years in practice: More than 20 years.

How did you begin reviewing for other journals and for JBJS in particular?

James Heckman was instrumental in establishing me as JBJS reviewer. We developed an intellectual bond, which continued in recent years with admiration for the dynamic leadership of Marc Swiontkowski for successful expansion and diversification of JBJS portfolio of journals. I am also fortunate to share excellent rapport with Editors of JBJS group of journals. I was highlighted by JBJS as a Top Reviewer for two successive years before achieving the current Elite Reviewer status.

I owe it to Greer Richardson for encouraging me as an International reviewer for Foot and Ankle International (FAI). Unusually he sent me two supportive complimentary e-mails regarding excellence of my first review for FAI, which boosted my indifferent initial confidence and laid the foundation for reviewer role for major international journals. Later I enjoyed an eventful close association with David Thordarson, who created the first and only International Assistant Editor post for me in FAI and then facilitated further listing as Editorial Board Member for active participation in Trans-Atlantic tele-conferences of the FAI Editorial Board.

I started as a reviewer for Clinical Orthopaedics and Related Research (CORR), when Richard Brand was Editor in Chief. I developed during Seth Leopold’s tenure as I was selected as a Top Reviewer for CORR and subsequently designated as an International Associate Editor with inspirational glimpses of editorial dynamics in implementation of a different philosophy of direction and publication of contemporary orthopaedic research with emphasis on quality of evidence and insights. In addition, a chance meeting in London with James Scott, the then-Editor-in-Chief, heralded reviewer role on this side of the Atlantic for JBJS Br (later designated Bone and Joint Journal) with subsequent addition of Bone and Joint Research.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

A perfect study does not exist and it follows that a perfect review is unattainable. Consistent efforts for excellence toward perfection as a hallmark of a review remain the ultimate aim. Conscious time limit, however, is not the main objective. It helps to expedite a review if the manuscript is read on the first day of acceptance with preliminary notations and certain undercurrents of thinking and analysis. At times, I follow it up with recent relevant literature review to clarify any doubtful issues and read the manuscript again after one or two days to draft the review in earnest. Knowing the particular journal well helps immensely. In my experience, the first draft of a review is not always the final draft. I would not submit a review until I am happy that it is comprehensive and certainly final. Recommendation also entails an element of balanced judgment. In the context of consistent efforts for uncompromising pursuit of excellence of reviews, the aim for Elite Reviewer status amounts to an incidental goal in the service of science and humanity as a team.

Aside from orthopaedic manuscripts, what have you been reading lately?

I regularly read classics and have a collection of several century-old Editions. It is a great pleasure to leaf through the great works of previous centuries. Recently I read a comparative work between Kalidasa and Shakespeare, arguably the greatest poets and dramatists in Sanskrit and English literature. Of late, I have become an admirer of John Greenleaf Whittier. I am also an avid reader of Victor Hugo, an illustrious French poet and novelist, whose prose even in translation sounds poetic. We had an occasion to visit the Residence of Victor Hugo in exile in Guernsey.

Finally, Keats remains a favourite poet. Pertinent to review of manuscripts, Keats’ famous first line of the first draft of Endymion was “A thing of beauty is forever a joy”, which he later modified to “A thing of beauty is a joy for ever”. This illustrates that even a greatest poet has to work on the first inspiration with an admittedly rare revision even after publication – highly relevant to a reviewer, particularly an Elite reviewer.

Learn more about the JBJS Elite Reviewers program.

ACL Grafts: Diameter Does Matter, Sort Of

Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.

In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.

However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.

One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.

Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: Robert Arciero

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Robert A. Arciero, MD

Affiliation: University of Connecticut Health

Years in practice: 32 years

How did you begin reviewing for other journals and for JBJS in particular?

I was asked by editors and/or associate editors because of my interests in shoulder and knee injuries in sports medicine.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

It may sound trite, but the reviewer must read the manuscript thoroughly and reflect on each aspect of the purpose, hypothesis, methods, results, and conclusion. Each section should be approached with a serious number of “why”s.

I think it is important that the reviewer have some command of the published literature on the particular topic and be willing to review that literature to review or comment on the manuscript.

Reviewing is a tedious process and takes time. It takes me routinely 1 to 2 hours to review properly.

Aside from orthopaedic manuscripts, what have you been reading lately?

I have been reading a lot about the Greatest Generation lately and biographies on some of my sports heroes — Ted Williams, Mickey Mantle etc. I also practice a lot of guitar.

Learn more about the JBJS Elite Reviewers program.

Elite Reviewer Spotlight: Jefferey Stambough

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Jeffery L. Stambough, MD, MBA

Affiliation: TriHealth Orthopedic and Sports Institute, Cincinnati, Ohio

Years in practice: 34 years

How did you begin reviewing for other journals and for JBJS in particular?

When I was a resident, my chairman, Carl T. Brighton, MD, encouraged us to get involved in orthopaedics and to give back. After my North American traveling fellowship, the late Dan Spengler, MD contacted me and, in the discussion, I asked to be involved in the fledgling Journal of Spinal Disorders. This was my first foray into the peer review process. 

What I learned from this experience is that if you want to get involved, just ask.  After gaining experience with spine journals, I volunteered to be a reviewer for JBJS. I have now been a reviewer for JBJS for about 20 years. More recently I have gotten more involved because I’ve been asked to do so.

The bottom line is that if you’re interested, fair-minded and committed, there’s an opportunity to become a peer reviewer specifically with JBJS. Just ask.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Be willing. While there may be a few perks, the bottom line is that you are interested and committed enough to do a good job. This includes but is not limited to being timely with your feedback, following a few basic rules and guidelines, and reviewing whatever you’re asked to as thoroughly as possible.

Aside from orthopaedic manuscripts, what have you been reading lately?

I frequently read The Bible.

Learn more about the JBJS Elite Reviewers program.

Elite Reviewer Spotlight: Donald Anderson

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Donald D. Anderson, PhD [most people call me by my nickname, “Don.”]

Affiliation: Department of Orthopedics & Rehabilitation, University of Iowa, Iowa City, IA

Years in practice: I am a full-time academic researcher, having completed my PhD in December 1989, which I guess means that I have “been in practice” for about 30 years now.

How did you begin reviewing for other journals and for JBJS in particular?

I began accepting requests to review manuscripts immediately after finishing up my PhD. Over the years, the number of journals that rely on my reviewing talents has increased. Somewhere along the way, JBJS started reaching out, and saying “yes” to that invitation was a pretty easy decision.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Be generous with your time, especially when the manuscript you’re referred is from your area of expertise and the study sounds interesting. It is okay to say “no” on occasion, but try to make that the exception. Then set a reminder for when the review is due and find a few hours to give it your full attention. Don’t sweat grammatical issues. Just tackle the big picture and technical points that occur to you.

Aside from orthopaedic manuscripts, what have you been reading lately?

I hate to admit it, but I read so much at work lately, that I don’t do much personal reading. However, as an engineer, I do complement my “orthopaedic manuscript” review work with comparable effort in the biomechanical engineering literature.

Learn more about the JBJS Elite Reviewers program.

FDA White Paper Cites JBJS “Case Connections” Article

There are 15 references to JBJS studies in the recently published 149-page white paper on “Biological Responses to Metal Implants,” from the FDA’s Center for Devices and Radiological Health. Most of those references are made in Section 7.5.1 (pp. 54-57), which focuses on orthopaedic devices.

The plethora of JBJS references is not surprising, but we were happy also to see that a JBJS “Case Connections” article was cited twice in the white paper. While most of the section on orthopaedic devices discussed metal-on-metal (MoM) hip problems, the FDA noted that adverse biological responses to metals in orthopaedics sometimes occur in the upper extremity. It did so by citing “Adverse Local Tissue Reactions in the Upper Extremity,” which appeared in the May 24, 2017 issue of JBJS Case Connector. The FDA white paper cautioned that metal wear debris-related adverse reactions have occurred with shoulder suture anchors (five cases of which are described in the “Case Connections” article) and with intramedullary humeral nailing (one case of which is described in the “Case Connections” article).

Among the take-home points made by co-authors Thomas Bauer and Allan Harper in the cited “Case Connections” article is this: “Patients with shoulder suture anchors who develop delayed-onset pain and/or stiffness, osteolysis, chondrolysis, or early arthropathy should be evaluated and consideration should be given to the removal of loose or prominent anchors to lessen the risk of articular damage.”

Surgeon Volume Matters for TKA Alignment

The retrospective multicenter study of 1,570 primary total knee arthroplasties (TKAs) by Kazarian et al. in the October 2, 2019 issue of JBJS focused on evaluating the impact of surgeon volume and training status on implant alignment. But the most surprising (and concerning) finding was that even among high-volume attendings—the best-performing of the three surgeon cohorts studied—the proportion of TKA alignment “outliers” was still high.

The authors radiographically measured 3 postoperative TKA alignment parameters: medial distal femoral angle (DFA), medial proximal tibial angle (PTA), and posterior tibial slope angle (PSA). Using established thresholds for “outliers” and “far outliers” for those 3 measurements, the authors compared the radiographic findings among surgeries performed by high-volume attendings (≥50 TKAs/year), low-volume attendings (<50 TKAs/year), and trainees (supervised residents or fellows).

As has been shown in similar studies of total hip arthroplasty (THA), the group of high-volume attendings outperformed the low-volume attendings and the trainee group on nearly all measurements assessed in this study. Interestingly, in terms of TKA alignment, the low-volume attending group and the trainee group performed similarly.

Kazarian et al. express concern that “even the most accurate cohort in our study, [the high-volume attendings], placed only 69.0% of knees in optimal alignment for all 3 measurements.” While the authors admit that implant alignment is not a perfect proxy for clinical outcomes, they argue that “gross alignment outliers are likely to have an impact on knee function, kinematics, and wear characteristics.” Citing literature suggesting that the use of robotic-arm assistance may improve TKA alignment, the authors surmise that employing such technology to assist low-volume surgeons or trainees might optimize alignment and improve outcomes, despite the added up-front cost of the technology.

Surgery for Rotator Cuff Tears: The Better of Two Goods

We’re all familiar with the phrase “lesser of two evils,” but I’m an optimist and prefer the phrase “better of two goods.” In the October 2, 2019 issue of JBJS, Ramme et al. compare surgical versus nonsurgical treatment of full-thickness rotator cuff tears. Both cohorts had improved outcomes relative to baseline, but surgical management was the better of two goods.

The authors retrospectively analyzed a prospective cohort of adult patients with full-thickness rotator cuff tears who had elected either surgical or nonsurgical treatment. Ramme et al. utilized propensity score matching to pair up patients in each group according to factors thought to influence outcome, such as age, sex, tear size, chronicity, muscle atrophy, and the Functional Comorbidity Index. This matched-pair analysis is a valiant attempt to eliminate bias that is inherent in retrospective analyses, and this study design also mimics the real-world scenario of shared decision making between physician and patient.

The 2-year follow-up analysis of 107 propensity score-matched patients revealed that both groups improved in 4 patient-reported functional outcomes and pain compared to their baseline measures before treatment. However, the final outcome measurements and magnitude of improvement were statistically greater in the surgical management group (p <0.001).

This study will help shoulder surgeons have more meaningful discussions with their patients about treatment options for full-thickness rotator cuff tears. We know that with proper treatment—either surgical or nonsurgical—patients can expect improvement in pain and function. However, patients who elect surgical management may have the potential for even greater outcomes, and that definitely sounds like the “better of two goods.”

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

Elite Reviewer Spotlight: Grant Jones

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Grant L. Jones, MD

Affiliation: The Ohio State University, Columbus, OH

Years in practice: 21 years

How did you begin reviewing for other journals and for JBJS in particular?

I first received an invitation to review articles for AJSM from a colleague I knew well.  Then through my contacts reviewing articles for AJSM, I started to receive invitations to review for JBJS.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Always accept articles to review, unless you have significant time constraints from travel or other educational activities.  If you are unable to review an article, give a detailed explanation why you are unable.  Take a significant amount of time at first when reviewing articles, as the authors have put a lot of time and thought into writing them.   Treat each article with respect. After reviewing several articles, one becomes more efficient and less time is required to review them.   Closely follow JBJS reviewer guidelines that are sent with the review invitations.  These guidelines really help you organize your reviews.   Provide constructive comments. Overly negative reviews without constructive suggestions are not helpful for the authors.  Finally, be punctual.  Start working on a review within a day or two of receiving it.  Otherwise the review loses priority and keeps on getting pushed down the to-do list, creating a situation where the reviewer has to rush to get it done to meet the deadline.

Aside from orthopaedic manuscripts, what have you been reading lately?

Other than reading JBJS, AJSM, and JSES, I read the local and national papers daily to keep up with current events.

Learn more about the JBJS Elite Reviewers program.