About a year ago, JBJS published its third biannual Role of the Orthopaedic Surgeon study. While intended primarily to inform suppliers about the procurement habits and needs of orthopaedic surgeons, this study contains much that is of interest to clinicians.
By clicking here and filling out a short form, you can download a 22-page executive brief of the 2015 study. Find out whether you and your practice are in step with the following trends:
- Hospital ownership of orthopaedic practices leveling off
- Orthopaedic practices hiring non-surgeons to relieve admin and clinical burdens (see chart above)
- Orthopaedic practices continuing to expand and diversify service offerings
- Surgeons retaining strong influence over device and equipment procurement
Coming soon: We’ll be reaching out this summer to orthopaedic surgeons for data for our 2017 Role of the Orthopaedic Surgeon study. That’ll be your best chance to let suppliers know what you want and need from them in order to help your patients.
In the meantime, click here to get a synopsis of what the 2015 study found.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD, in response to two recent NEJM studies on treating spondylolisthesis.
The April 14, 2016 edition of The New England Journal of Medicine published results from two randomized clinical trials (RCTs) evaluating the benefits of laminectomy alone versus laminectomy and fusion for the treatment of specific spinal conditions in patients 50 to 80 years old, with at least 2-year follow-up. The larger study was conducted in Sweden and included 247 patients, 135 of whom had degenerative spondylolisthesis of some magnitude. In this study, the surgical technique varied and was left to the treating provider’s preference. The ultimate conclusion of this study was that adding fusion to the procedure did not result in better patient outcomes by any index measured.
Conversely, an essentially concurrent but unrelated RCT evaluating similar outcomes in a US patient population (n=66) with degenerative spondylolisthesis that measured at least 3 mm, but in which there was no instability, concluded that spinal fusion, using a standardized technique (pedicle screws and rods with iliac crest bone graft), did provide a significant clinical benefit. Specifically, this study found significant improvement in SF-36 physical-component summary scores (the primary outcome measure) and lower reoperation rates (14% vs. 34%; p=0.05) compared to decompression alone.
When two Level 1 studies published on the same day in the same high-impact journal come to divergent conclusions about the same clinical question, we must pause and look to the past. Spine surgeons have investigated decompression alone for spondylolisthesis, first by necessity (prior to the era of reliable spinal fusion) and then later in comparison to in-situ and instrumented fusion1,2. Consensus is consistent with anatomic reasoning. Dysfunctional lumbar mobile segments, especially those with preserved or excessive motion (i.e. >2 to 4 mm change on flexion-extension films), produce a mechanical pathoanatomic sequence of events that leads to critical and clinically symptomatic spinal stenosis. Addressing this first cause is paramount.
The immediate effect of surgery type is largely neutralized by the fact that the decompression component, which is common to both approaches, is principally responsible for acute improvement. Because most prospective studies are not able to reliably track patients beyond 2 to 5 years, the longer-term benefits of a solid arthrodesis of a dysfunctional spinal-motion segment compared to a simple decompression in which some of the incompetent posterior elements are further surgically removed remain largely unknown. Anecdotally, spine surgeons recognize that failures of decompression alone in mobile spondylolisthesis occur quite frequently—and that revision fusion surgery in this situation is significantly more complicated than primary decompression and fusion. That was the case in the Swedish study, where the majority of revision surgeries in the decompression-only cohort were performed at the same level as the prior surgery, versus adjacent levels in the fusion group. And, again, reoperation rates were significantly higher (>2x) in the decompression-only group in the US study.
Given conflicting data3, there likely are cofactors that need to be identified and further studied to select cases of spondylolisthesis that can be treated well with decompression alone, versus those that require the stabilizing effect of a fusion. Until then, surgeons must weigh the data available and provide the surgical option they feel is best for each individual patient.
Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN
- Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976). 1997 Dec 15;22(24):2807-12.
- Bridwell KH, Sedgewick TA, O’Brien MF, Lenke LG, Baldus C. The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord. 1993 Dec;6(6):461-72.
- Joaquim AF, Milano JB, Ghizoni E, Patel AA. Is There a Role for Decompression Alone for Treating Symptomatic Degenerative Lumbar Spondylolisthesis?: A Systematic Review. J Spinal Disord Tech. 2015 Dec 24. [Epub ahead of print]
To help welcome the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) into the JBJS family of peer-reviewed journals (see related OrthoBuzz post), JBJS is offering five $1000 awards, as follows:
- 3 for the three best review articles authored by a certified, practicing PA or NP
- 2 for the two best review articles authored by a PA student (student authors are strongly encouraged to partner with a supervising PA, MD, or DO)
Eligible articles (≥ 1200 words, excluding references and figure legends, plus a 100-word abstract) are academic reviews on a broad orthopaedic topic OR concise overviews of a single clinical condition or orthopaedic procedure. For details about authoring JOPA articles, read the JOPA Instructions for Authors.
Deadline for submission is December 31, 2016.
Enter the contest by submitting your article via the JOPA Editorial Manager site.
Please address questions regarding the contest to email@example.com.
JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) are pleased to announce two awards in the amount of $500 US each. One award will be for the best orthopaedic surgical technique article, and the other will be for the best Key Procedures (KP) video submitted in 2016.
Key criteria for a high-quality EST article include, but are not limited to:
- Clearly written step-by-step instructions (for EST papers) or a comprehensive storyboard (for KP video submissions)
- High-resolution, instructive video clips
- Clinical relevance of technique or procedure
Winning authors will be notified in February 2017. Their achievement will be recognized online as well as during the JBJS reception at the AAOS Annual Meeting in March 2017.
Questions regarding the contest and submission process can be sent to firstname.lastname@example.org.
OrthoBuzz regularly brings 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 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.
In 1957 Gerhard Küntscher presented his work on intramedullary (IM) nailing to the American Academy of Orthopaedic Surgeons. His classic JBJS paper on the subject, published in January 1958, summarized his views on this comparatively new technique and encouraged other surgeons to use it for the treatment of long bone fractures and nonunions.
Küntscher pointed out that callus was very sensitive to mechanical stresses, and therefore any treatment method should aim at complete immobilization of the fracture fragments throughout the healing process. External splints, such as plaster casts, did not achieve that, and “inner splints” fixed to the outside of the bone damaged the periosteum.
In advocating for intramedullary fixation, Küntscher was careful to distinguish nails from pins. He was very complimentary about J. and L. Rush, who developed intramedullary pinning, but he pointed out that, unlike pins, nails allowed both longitudinal elasticity and cross-sectional compressibility if they were designed with a V-profile or clover-leaf cross section. This cross-sectional elasticity allowed the nail to fit the canal and expand during bone resorption.
Not only did Küntscher appreciate the biomechanics of the intramedullary nail, but he also pointed out the physical and psychological advantages of early mobilization, particularly in the elderly. He also emphasized that massage was unnecessary—and potentially harmful—during the recovery phase, claiming that any measures that make patients more conscious of their injuries are psychologically disadvantageous.
Küntscher used intramedullary nailing to treat fractures, nonunions, and osteotomies of the femur, tibia, humerus, and forearm. He accepted that it was “a most daring” approach that would destroy the nutrient artery, but he pointed out that proper nailing almost always prevented pseudarthoses and that antibiotics had checked the threat of infection. He said further that perioperative x-rays entailed short exposures and that the “electronic fluoroscope” had, even back then, practically eliminated the risk of x-ray injury to assistants.
The paper clearly illustrates Küntscher’s widespread knowledge and innovative skills. However, it was the subsequent development of locked nails that resulted in intramedullary nailing becoming the treatment of choice for femoral and tibial fractures. Time will tell if modern orthopaedic surgeons will catch up with Küntscher and use nailing for humeral and forearm diaphyseal fractures.
Charles M Court-Brown, MD, FRCSCEd
JBJS Deputy Editor
I recently returned from the 13th meeting of the Combined Orthopaedic Associations, affectionately known as COMOC 2016. This meeting is unique in that it brings together seven different national orthopaedic organizations from six countries (America, Australia, Britain, Canada, New Zealand, and South Africa).
The concept for this combined meeting originated with R.I. Harris, a Canadian orthopaedic surgeon who had been the president of both the Canadian Orthopaedic Association and the American Orthopaedic Association (AOA). Dr. Harris felt that improved communication between American, British, and Canadian orthopaedic surgeons would be of benefit to all. He was also responsible for the institution of the American-British-Canadian (ABC) Traveling Fellowship.
The first combined meeting involved only US, Canadian, and British orthopaedic surgeons. At that time travel would have been by ship or train. The original idea was to hold this meeting every six years and to move the venue from country to country on a predetermined schedule. This year, COMOC was held in Cape Town, South Africa, and in six years the US will be the host country.
The structure of the meeting is unique in that countries are given a forum to present orthopaedic issues most relevant to their national organizations. On Monday, April 11, both the American Academy of Orthopaedic Surgeons and the AOA presented plenary sessions. On Tuesday Australia took its turn in the morning, and New Zealand presented in the afternoon. Wednesday saw a presentation from the United Kingdom, with Canada taking the podium on Thursday. The plenaries wrapped up on Friday with the host South African Orthopaedic Association.
This meeting is an enduring link with the past and the future, continuing the orthopaedic tradition of fellowship and friendship that is the hallmark of our specialty. The Cape Town meeting was exceptional in venue, content, and organization. The Local Organizing Committee and Programme Committee are to be congratulated for an exceptional job in developing a program that maintained significant audience interest despite the competing attractions of Cape Town and the South African countryside.
When COMOC comes to America in 2022, I hope North American orthopaedists—especially younger ones—will take the once-in-a-career opportunity to meet and talk with musculoskeletal colleagues from all over the world.
James P. Waddell, MD, FRCSC
JBJS Deputy Editor
Obesity can negatively affect outcomes after total hip arthroplasty (THA), and an inadvertent reduction in cup anteversion may be one reason why, according to findings from Brodt et al. in the May 4, 2016 edition of The Journal of Bone & Joint Surgery.
The authors retrospectively analyzed postoperative radiographs from 790 THA patients (all of whom were operated on via a direct lateral approach) within three BMI ranges: normal weight (BMI <25 kg/m2), moderately obese (BMI between 25 and 34 kg/m2), and morbidly obese (BMI of ≥35 kg/m2). Reduced cup anteversion significantly correlated with increasing BMI and younger patient age, with the morbidly obese group demonstrating a 3.4° anteversion reduction compared with the normal-weight group. The authors attribute the reduced anteversion to increased pressure applied to dorsal and ventral acetabular rim retractors to ensure adequate visualization during THA surgery in obese patients.
When the authors applied their findings to the Lewinnek “safe zone” for acetabular positioning, only 59% of the morbidly obese patients were in that zone. While this study was not designed to track subsequent dislocations (a common consequence of incorrect cup positioning), the authors claim that these findings are nevertheless clinically important. “Knowledge of a systemic error in obese patients should raise surgeons’ awareness of the need to perform cup implantation with greater attention,” they conclude.
In the May 4, 2016 issue of The Journal, Gruca et al. describe the very effective outreach efforts among Iowan orthopaedic surgeons to rural patients throughout their state. Iowa’s orthopaedic surgeons have demonstrated a high degree of commitment to staffing so-called visiting consultant clinics (VCCs) in rural communities. Forty-five percent of all Iowa-based orthopaedists traveled a cumulative total of 32,496 miles per month during 2014 to staff VCCs.
No matter where they live, patients typically do not like to travel far for medical care. For conditions like cancer or severe cardiac disease, the prospect of travel may be more acceptable, because patients and families feel that the potential for significant illness or death warrants “whatever it takes” to gain access to the highest level of expertise available. But for routine musculoskeletal diagnoses such as osteoarthritis of the knee or rotator cuff tendinosis, the option of gaining access to a high degree of expertise closer to home is very appealing.
I wonder, however, whether the loss of time and expertise entailed with surgeons driving long distances makes sense. My hunch is that in the next few years, web-based telemedicine—which Gruca et al. say was lagging in Iowa at the time of their study—will become the norm for delivering specialty care to rural communities. Also, while it probably doesn’t make sense to outfit and staff small rural critical-access hospitals to do complex orthopaedic surgical procedures, it might be sensible in those settings to use local “physician extenders” for outpatient consultation and pre- and postoperative care. I predict that we will soon see manuscripts submitted to The Journal documenting the quality and cost-effectiveness of care delivered to “geographically disadvantaged” patients in those alternative ways as well.
Marc Swiontkowski, MD
Between 2000 and 2014, 1573 wounded US service members sustained one or more major amputations, and nearly two-thirds of those individuals developed posttraumatic heterotopic ossification (HO). Deciding when to excise HO (which can cause pain and interfere with rehabilitation programs and prosthetic limbs) requires careful consideration, and findings from a study by Isaacson et al. in the April 20, 2016 JBJS may help surgeons and patients faced with that decision.
Using sophisticated microscopy techniques to analyze symptomatic heterotopic bone excised from 33 service members following combat-related trauma, Isaacson et al. determined that mineral apposition rates in the HO specimens averaged 1.7 μm/day, which is 1.7 times higher than the 1.0 μm/day rate typically found in non-pathological human bone. The authors also found a direct relationship between mineral apposition rates and clinical predictors of HO, such as traumatic brain injury. The findings further suggested that mineral apposition rates correlate with the severity of HO recurrence.
Although the mineral apposition rates increased along with the time from injury to excision, the authors concluded that “the optimal time to resect symptomatic HO must still be a clinical decision,” and they call for further investigation into correlations between mineral apposition rates and HO development and recurrence.
Musculoskeletal (MSK) infections are highly prevalent and potentially serious, and orthopaedists are frequently faced with preventing and treating them. Wherever or however they are acquired, these pathogen-based conditions are among the most challenging to address effectively.
On Monday, May 23, 2016 at 8:00 pm EDT, The Journal of Bone & Joint Surgery will present a complimentary webinar that includes findings from two recent JBJS studies that explore how best to prevent deep infections in lower-grade open fractures, and the most effective antibiotics for treating community-acquired hand infections.
Richard Jenkinson, MD will discuss findings from a cohort study that compared deep infection rates in patients with lower-grade open fractures who were treated with either immediate wound closure or delayed wound closure. Rick Tosti, MD will examine resistance patterns of specific antibiotics to MRSA infections of the hand in an urban population.
Moderated by musculoskeletal-infection expert Jonathan Schoenecker, MD, PhD, the webinar will also feature commentaries on the studies by Lawrence Marsh, MD and Isaac Thomsen, MD.