Archive | October 2014

New Leadership at The Journal

The Board of Trustees of The Journal of Bone and Joint Surgery, Inc., is pleased to announce new leadership at STRIATUS/JBJS.  Mady Tissenbaum, formerly Associate Publisher and General Manager, has stepped into the role of Publisher, while Paul Sandford, formerly the Chief Financial Officer, will serve as CEO.

“We are fortunate to have such strong leaders within the JBJS organization. With the departure of Kent Anderson, who held the post of CEO and Publisher, we did not have to look far to identify who we felt could best ensure continued success for The Journal,” explained Richard Gelberman, MD, Chair of the Board of Trustees.  “Together, Mady and Paul bring enormous skill and experience in publishing, strategic planning and finance.  Further, they have a strong history of operational leadership and effectiveness in working together with our Board of Trustees.”

“The focus of The Journal remains the same: to provide the most valued orthopaedic information across our portfolio of four journals, to offer practical continuing medical education solutions  for our audience, and to continue to support the highest standards of unbiased, peer reviewed, scientific literature, ” commented Tissenbaum.

Sandford added, “This is an exciting time for The Journal as we celebrate our 125th anniversary.  We have a dedicated and talented team in place to ensure that the organization continues to produce high-quality, actionable content for the next 125 years and beyond, as we continue to reflect and adapt to changes both in orthopaedics and in publishing.”

3D-Printed Heel Bone Averts Amputation for Australian Man

Len Chandler of Melbourne, Australia had a cancerous tumor in his left calcaneus and was facing a below-the-knee amputation because of the difficulty entailed in achieving a functional limb salvage procedure. Surgeon Peter Choong teamed with an implant manufacturer and Australia’s national science agency to create an exact titanium replica of the involved bone. The 3D-printed bone had to be both porous, to allow tissue in growth, and ultra-smooth so that it could articulate with hind and midfoot joints, and allow smooth tendon gliding.

After this ground-breaking surgery in July, Chandler is now able to carry more than half his body weight on that foot. The prognosis is for Chandler to be off crutches by the end of 2014. Click here to read the full story. Also, read the related OrthoBuzz article about the first 3D-printed cervical disc implanted in a minor.

Super-Slippery Device Coating Prevents Blood Clots and Bacterial Adhesion

Whenever physicians implant a “foreign” device in the body, as orthopaedists often do, the implant is up against two crucial challenges: blood clots and bacteria. Solving both of those challenges took a big step forward with the recent publication in Nature Biotechnology of results with a new device-surface coating that thwarts blood clotting and keeps certain bacteria from sticking to it through glycocalyx formation. The repellant coating, called tethered-liquid perfluorocarbon, or TLP, is a modified version of the super-slippery stuff that the carnivorous pitcher plant uses to catch insects.

Harvard researchers tested the coating, the two constituents of which are already FDA-approved, in vitro on 20 different medical surfaces, including glass and metal, where it suppressed platelet adhesion and activation under simulated blood flow. They also tested it in vivo with catheters implanted into the large veins of pigs, where it prevented blood clotting for eight hours without the use of anticoagulants. In another in vitro experiment during which TLP-coated medical tubing was exposed to Pseudomonas aeruginosa for six weeks, only one in a billion of the bacteria were able to adhere.

It’s too early to say with certainty if and when TLP coatings might be ready for use on orthopaedic implants, but the approach raises hopes that a powerful new preventer of two major complications associated with orthopaedic device implantation is feasible in the near future.

A Conversation with Thomas Thornhill, MD

ThomasThornhillThomas Thornhill, MD is the John B and Buckminster Brown Professor of Orthopaedic Surgery at Harvard Medical School and Chair of the Department of Orthopaedics at Brigham and Women’s Hospital in Boston. He recently was kind enough to answer a few questions for OrthoBuzz.

JBJS: What are some of the most significant changes in orthopaedics you have observed during your career?

Dr. Thornhill: The quality of applicants to orthopaedic residency programs seems to improve every year. I think anyone involved today in choosing new residents feels that he or she would never have been chosen by contemporary standards. Moreover, our profession has become more diverse, which is a good thing. Our residency/fellowship program has a significant number of women and underserved minorities. The most impressive thing is that there is a single set of criteria for all applicants, giving us a uniformly outstanding resident pool.

Also, the emerging use of biologics has enhanced our ability to care for some common and uncommon musculoskeletal problems. For example, the use of disease-modifying anti-rheumatic drugs (DMARDs) has revolutionized the care of the rheumatoid patient. When I began practice, 80 percent of patients undergoing total joint arthroplasty had rheumatoid arthritis, and now it is only approximately 10 percent in a center well-known for treating the rheumatoid patient.

Third, I’ve seen significant changes in the globalization of orthopaedics. The internet and social media have improved global communication. Many of the meetings in arthroplasty are global in their scope, and we are learning a tremendous amount from our orthopaedic colleagues around the world.

JBJS: Brigham and Women’s Hospital is recognized as a leader in providing patient-centered, team-based care. Why is this approach so important to orthopaedic patients?

Dr. Thornhill: Brigham and Women’s Hospital does not exist in a vacuum, and the Boston area has many fine academic and community hospitals with strong orthopaedic programs. Each subscribes to the concept of providing the right care, at the right place, and at the right time. Moreover, the changes in healthcare systems in Massachusetts and throughout the United Sates require each of us to be innovative. In the past, clinical surpluses could be used for educational and research program funding, but with the shrinking healthcare economy, there are many essential, but non-remunerative programs that are in jeopardy. Efficient, team-based care is one way to ensure we have the resources to continue these important educational and research programs. Finally, the switch from fee-for-service to episode-of-care reimbursement and population health is going to require each of us to adjust to inevitable changes in healthcare. In this environment, patient-centered, team-based care makes the most sense to ensure optimal outcomes.

JBJS: Orthopaedists are increasingly focused by subspecialty. What do you see as the benefits and risks of increased subspecialization within orthopaedics?

Dr. Thornhill: We are indeed becoming more and more subspecialized. One benefit is that it will certainly improve expertise in these areas, where patient demand is growing in an exponential fashion. It will also allow specialists to remain current in their subspecialty and prompt innovation in these different fields of orthopaedic practice.

On the other hand, intensive subspecialization may prevent us from “thinking outside the box.” Communication and idea crossover are important, and while we know many of the leaders in our own subspecialty, we don’t know many in other areas. Most of the meetings now are subspecialty-driven and fail to benefit from sharing of ideas with other subspecialties. Our graduates now virtually all take a fellowship, and 15 percent of them take two fellowships. One could argue that a trauma surgeon or musculoskeletal oncologist should have arthroplasty experience because there is a good deal of overlap within these disciplines. We should also remember that lessons learned in one specialty may benefit another. For instance, hip surgeons have long considered neck shaft angle, offset, and even material properties that have now been incorporated into the design and implantation of shoulder prostheses.

JBJS: How do you think JBJS can best address the needs of the orthopaedic community in light of this increasing subspecialization?

Dr. Thornhill: JBJS needs to maintain its preeminence as the leading orthopaedic journal. To do so, it must remain relevant, explore other mechanisms in addition to a printed version to transmit information, and the articles must remain balanced throughout the various subspecialties. I think JBJS has done an outstanding job moving into electronic media. One concern is the economics of maintaining The Journal’s viability and the concerns of some young authors about the cost of submitting a manuscript.

JBJS: Looking ahead to the next 20 years or so, what three significant advances or changes in orthopaedics do you foresee?

Dr. Thornhill: To paraphrase the book Future Shock, “If you want to see what is in the future, look around because it is happening somewhere now.” I think there will be an increased use of biologics in applications such as induction of bone formation, cartilage repair, tissue engineering, and the use of stem cells for repairing and regenerating musculoskeletal structures.

Also, we will look back several years from now and laugh at the materials we currently use for total joint replacement. One important concern in my area of interest is that 15 to 20 percent of patients undergoing total knee replacement are not completely satisfied, while many people with total hips and total shoulders forget they had an implant. I think the cause is multifactorial, but I do think that we will develop or engineer materials with characteristics that will improve the kinematics of knee prostheses, and hopefully our patients will feel that their knee replacements are more normal.

Finally, there will be an increase in technology, manufacturing, and research and development on a global scale. Global cooperation and time zone differences can allow manufacturing, design, and outcome studies to occur 24-7 in a more cost-effective fashion. If we also foster the interactions between academia and industry in a controlled fashion, we will further appreciate the tremendous advances in our specialty due to these relationships.

JBJS: What is your favorite thing about your profession?

Dr. Thornhill: The hackneyed phrase is that we get instant gratification from pain relief and restoration of function in our patients. While this is true, when I trace my training from internal medicine to orthopaedics, I recall drawing a Venn diagram showing that the three things I liked the best were surgery, rheumatology, and neurology. The only true intersection among those is orthopaedics. I would say that other than my family, I appreciate my interactions with students, residents, fellows, and colleagues, and I thoroughly enjoy treating my patients as people. Finally, I like the operating room and the technical aspects of orthopaedics.

JBJS: Thank you, Dr. Thornhill, for your time.

JBJS Classics: ACL Graft Strength and Stiffness

Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

JBJS-Classics-logoIn the classic article, “Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions” (J Bone Joint Surg Am 1984; 66:344–352), now 30 years old, Noyes and colleagues studied the mechanical properties of several anterior cruciate ligament (ACL) grafts that were used at that time. Using young donors, they found that the bone-patellar tendon-bone (BPTB) graft was the only graft studied that had a maximum load in excess of the native ACL. Many of the grafts they studied—including iliotibial tract, fascia lata, and quadriceps retinaculum—had exceedingly poor strengths, which is probably why they are no longer used.

Unfortunately, the authors did not double their hamstring grafts (as is commonly done clinically) for testing, and they also used 14-mm BPTB grafts, which are much wider than commonly used clinically, so some of their comparisons may have limited clinical applicability. The authors did note several limitations to their study, including that graft strength is only one of many factors for successful ACL reconstruction, that gripping was sometimes a problem during testing, and that they only performed uni-axial testing. Nevertheless, this article set the stage for critically analyzing graft choice based upon mechanical properties.

Subsequent studies, including those by Woo, Cooper, Howell, Brown, and others, now suggest that several grafts are available that are stronger and stiffer than the native ACL, including BPTB, quadrupled hamstring (strongest and stiffest of all grafts studied), quadriceps tendon, tibialis anterior tendon, and posterior tibial tendon:

Graft Type Ultimate Strength(N) Stiffness (KN/m)
Native ACL 2160 292
BPTB 2977 620
Quadrupled Hamstring 4590 861
Quadriceps Tendon 2352 463
Tibialis Anterior 3412 344
Posterior Tibialis 3391 302

Of course, many other ACL reconstruction controversies continue to be debated, including technique, fixation, and autograft vs. allograft. But graft strength and stiffness will continue to be one of many important factors for the ACL surgeon to consider, especially if future options such as ACL augmentation and the use of synthetics and biologics become available. We welcome comments from JBJS readers.

Mark D. Miller, MD

JBJS Deputy Editor for Sports Medicine

JBJS/JOSPT Joint Webinar: Return to Sports after ACL Reconstruction

“When will I be able to play again?” Following ACL reconstruction surgery, that’s a question orthopaedic surgeons and physical therapists invariably hear—often repeatedly—from their athletically inclined patients.

The multiple surgical, rehabilitative, and patient-centered factors that go into answering this difficult question are the subject of this free webinar, hosted jointly by The Journal of Bone and Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT).

This webinar will focus on the following two articles, one from each journal:

•      Operative Treatment of Primary ACL Rupture in Adults (JBJS 2014; 96:685-94)
•      Return to Preinjury Sports Participation Following ACL Reconstruction: Contributions of Demographic, Knee Impairment, and Self-report                     Measures (JOSPT 2012; 42:893-901)
After the articles’ primary authors present their data, two additional return-to-sports experts will add their perspectives to this body of research. The audience will have the opportunity to ask questions of the presenters.

Sign up for the November 12th webinar today!


Answers to FAQs on Orthopaedic Coding

AAOS Now answers commonly asked coding questions for orthopaedic practices. This month’s column by Mary LeGrand, RN, senior consultant with KarenZupko & Associates, specifically addresses the following thorny coding issues in a Q&A format:

  • Coflex interlaminar technology
  • Modifier 51 or 59 in relation to intra-articular injections
  • Open surgery for femoroacetabular impingement (FAI) syndrome
  • Diskectomy and stenosis procedures
  • ACL reconstruction

Use of Google Glass with EHRs Expanding

Google Glass is expanding its medical applications far beyond capturing and transmitting videos of surgery. Google Glass is now entering and retrieving patient information into and from electronic health records. A pilot test of Google Glass and Augmedix taking place at Dignity Health’s Ventura Medical Clinic involves three family practices and over 2,700 patients. Physicians using Google Glass have reported a major drop in daily time spent entering info into the EHR from 33% to 9% and an increase in direct patient care time from 35% to 70%. Participating doctors put on Google Glass prior to meeting with the patient. During the visit, Augmedix software captures the audio and video through the device and enters it into the EHR system. The doctor can also ask questions to retrieve certain types of information such as lab-test results. (See related OrthoBuzz item from May 2, 2014.)

Bidding on Medical Services Raises Quality, Ethical Concerns

According to a report on (registration required), for Francisco Velazco, an unemployed Seattle handyman, an online auction yielded an affordable solution to getting his torn ligament repaired. Without health insurance and unable to pay the $15,000 estimated cost from a local provider, Velazco turned to MediBid, an online medical auction site that matches patients who are seeking non-emergency treatment with physicians. MediBid doesn’t check provider credentials but requests physician license numbers so prospective patients can check on the physician’s credentials themselves.

Valazco paid $25 to post his request for surgery and a few days later he had bids for outpatient treatment from surgeons in New York, California, and Virginia. One bid for $7,500 included the anesthesia and related costs and information about orthopaedist Dr. William T. Grant in Charlottesville, Virginia. Velazco eventually underwent surgery in an outpatient surgical center that Dr. Grant co-owns. This was Dr. Grant’s first MediBid case, and he said, “I was certainly invested in wanting this to be a positive experience for everybody.” According to Velazco, the experience was ideal.

About 120,000 consumers have used MediBid, with many of them uninsured or covered by high-deductible health plans. On the provider end, there are about 6,000 physicians or surgery centers on board with MediBid, and they too pay a fee to bid on requests.

Not surprisingly online auctions for medical services have critics, among them Arthur L. Caplan, head of the division of bioethics at New York’s Langone Medical Center, who said, “Cheap sounds good, but in these auctions you’re not getting any information: Was the guy at the bottom of his class in medical school?”

Doctor Shopping for Narcotics Common among Trauma Patients

A study in the August 6, 2014 JBJS revealed that the prevalence of postoperative “doctor shopping” among a cohort of 130 orthopaedic trauma patients in Tennessee was a surprisingly high 20.8%. This study used the state-controlled substance monitoring database to identify the narcotic prescriptions filled by patients three months prior to surgery and up to six months after discharge. The study segmented the test group into those who received prescriptions only from the treating surgeon or healthcare extender and those who got prescriptions from multiple doctors and extenders.

According to the study, patients who doctor shopped received an average of seven prescriptions for narcotics compared to an average of two prescriptions among those who got prescriptions from a single provider. Those with a high-school education or less were three times more likely to seek out multiple providers. According to Dr. Douglas Lundy, a spokesperson for the American Academy of Orthopedic Surgeons, “I think what the study tells us is there is a subgroup of patients you need to be a little more vigilant on, that they may be taking more drugs than you think they’re taking.”