Archive | September 2016

Long-Term Revision Rates after Cervical Spine Arthrodesis

cervical-arthrodesisMost studies looking into revision rates after cervical spine fusion follow patients for 2 to 5 years. But in the September 21, 2016 issue of JBJS, Derman et al. investigate revision rates—and risk factors for revision—with a follow-up of 16 years.

Analyzing New York State’s SPARCS all-payer database, the authors identified more than 87,000 patients who underwent a primary subaxial cervical arthrodesis from 1997 through 2012. During the study period, 7.7% of the patients underwent revision, with a median time to revision of 24.5 months.

Cervical arthrodeses performed with anterior-only approaches had a significantly higher probability of revision than those performed via posterior or circumferential approaches. The authors also found that the following characteristics were associated with an elevated revision risk:

  • Patient age of 18 to 34 years
  • White race
  • Workers’ Compensation or Medicare (but not Medicaid) coverage
  • Arthrodeses to address spinal stenosis, spondylosis, deformity, or neoplasm

Shorter arthrodeses (i.e., fewer fusion levels) and arthrodesis to address fractures were associated with relatively lower revision risks.

The authors conclude that “knowledge of these factors should help to promote exploration of strategies to reduce the prevalence of revision(s)…and to facilitate more accurate preoperative counseling of patients.”

JBJS Reviews Editor’s Choice—Pediatric Infection

Untitled-2.pngInfection, whether acute, chronic, local, or systemic, is something that all surgeons respect and fear. To counter infection, tissue injury activates an acute-phase response mediated by the liver and promotes coagulation, immunity, and tissue regeneration. However, microorganisms are able to survive and disseminate throughout tissues because of virulence factors that they express. These virulence factors help to modulate and hijack the acute-phase response.

In this month’s Editor’s Choice article, An et al. discuss how an understanding of virulence strategies of musculoskeletal pathogens will help to guide clinical diagnosis and decision-making through monitoring of acute-phase markers such as C-reactive protein, the erythrocyte sedimentation rate, and fibrinogen. As pathogenic bacteria possess virulence factors that allow them to invade, persist, and disseminate within the human body, this review focuses on the pathophysiology of musculoskeletal infection and the virulence factors that enable pathogens to thrive within the context of tissue damage.

The authors demonstrate that tissue injury ruptures anatomic compartment boundaries, leading to the contamination of microenvironments that require complex physiological processes for proper temporary repair. Certain organisms, such as Staphylococcus aureus and Streptococcus pyogenes, have evolved mechanisms for evading and hijacking the hemostatic, tissue regenerative, and antimicrobial properties of the acute-phase response. Indeed, a better understanding of the virulence strategies used by pathogenic microorganisms should enhance our ability to treat infections and improve patient outcomes in the future.

Thomas A. Einhorn, MD
Editor, JBJS Reviews

JBJS Classics: The Natural History of Congenital Scoliosis

jbjsclassics-2016OrthoBuzz 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.

Michael McMaster, a widely respected and well-published orthopaedic surgeon from Edinburgh who treated a great number of pediatric spinal deformity patients over a 36-year career, published this classic JBJS article more than 30 years ago. His report continues to serve as the basis for what we as pediatric spinal deformity surgeons recommend for treatment in children with congenital scoliosis. The classification that he proposed allows us to know early in childhood which congenital scoliosis patients require early, aggressive treatment and who can be followed with little need for treatment.

By assessing 251 growing patients with congenital scoliosis in a longitudinal manner, Mr. McMaster determined the rate of progression with growth for 5 different primary curve types. The most progressive deformity is a unilateral vertebral bar (failure of segmentation) with a contralateral hemivertebra (failure of formation). Common congenital single hemivertebrae worsen most in the thoracolumbar and lower thoracic areas, and all hemivertebrae progress at a faster rate after 10 years of age than prior to age 10.

Knowing the natural history of any deformity in pediatric orthopaedics is the major factor in determining the need for treatment.  Mr. McMaster here provided the pediatric spinal deformity surgeon with essential information that still guides our treatment of congenital scoliosis on a daily basis today.

Vernon T. Tolo, MD
JBJS Editor Emeritus

What’s New in Musculoskeletal Infection: Update on Biofilms

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Arvind Nana, MD, co-author of the July 20, 2016 Specialty Update on musculoskeletal infection, selected the three most compelling discoveries from among the more than 100 studies cited in the Specialty Update, which focused on biofilms.

Dr. Nana and his co-authors provide a concise primer on the biology of biofilms, the network of microorganisms that adhere to implant surfaces and form a complex structure surrounded by a self-generated extracellular polymeric matrix. This matrix not only anchors bacteria to orthopaedic implants, but also provides a nearly impenetrable defense mechanism against the host immune system. Staphylococci are the most common biofilm-forming bacteria found in orthopaedics.

Persister Cells in Biofilms

So-called persister cells have an inherent tolerance to antimicrobial agents. Misconceptions about persisters have permeated the literature. The authors provide clarification about persisters:

  • Persister cells CAN be reliably killed when the antimicrobial concentration is high enough. The minimum biofilm eradication concentration (MBEC) is lower when antimicrobial exposure is continuous and prolonged.1
  • Decreasing the number of microorganisms with antimicrobial intervention is NOT good enough. Cure requires the total elimination of all viable microbes.

Biofilm in Orthopaedic Trauma

Biofilm formation in the setting of open fractures is concerning because biofilm can develop on bone and in soft tissues in a matter of hours. The assumption is that appropriate surgical techniques for open fractures, including therapeutic antibiotic administration, can decrease bioburden and provide fracture stability, thus modulating the acute, local inflammatory response and minimizing biofilm formation.2 However, current technology does not enable noninvasive quantification of biofilm activity and presence in a stable open fracture following wound closure.

Biofilm in Total Joint Arthroplasty

Traditionally, prosthesis-related biofilm infections in the US have been treated by a 2-stage exchange arthroplasty. Although biofilm from the implant is removed by extraction of the components, the potential exists for persistence of biofilm in the surrounding soft tissues. Most patients treated for periprosthetic joint infections also receive intravenous antibiotics, but a recent in vitro study demonstrated that administering cefazolin even at increased concentrations still resulted in persistent Staphylococcus biofilm on cobalt-chromium, polymethylmethacrylate, and polyethylene,3 which supports the need for explantation.

There is still room to develop novel treatment methods for eradicating biofilm in periprosthetic joint infections. Future novel treatment methods for eradicating implant biofilm will help minimize the morbidity associated with current accepted periprosthetic joint infection treatment options.


  1. Castaneda P, McLaren A, Tavaziva G, Overstreet D. Biofilm antimicrobial susceptibility increases with antimicrobial exposure time. Clin Orthop Relat Res. 2016 Jan 21.
  1. Pfeifer R, Darwiche S, Kohut L, Billiar TR, Pape HC. Cumulative effects of bone and soft tissue injury on systemic inflammation: a pilot study. Clin Orthop Relat Res. 2013 Sep;471(9):2815-21.
  2. Urish KL, DeMuth PW, Kwan BW, Craft DW, Ma D, Haider H, Tuan RS, Wood TK, Davis CM 3rd..Antibiotic-tolerant Staphylococcus aureus biofilm persists on arthroplasty materials. Clin Orthop Relat Res.2016 Feb 1.

JBJS/JOSPT Webinar: Basilar Thumb Arthritis—October 13, 1:30 PM EDT


Thumbs account for approximately 40% of human hand function, playing a critical role during work, play, and activities of daily living.  Arthritis at the base of the thumb (basilar or trapeziometacarpal joint) is one of the most common forms of hand osteoarthritis, affecting as many as 40 percent of the female population older than 55.

This complimentary webinar, hosted jointly by The Journal of Bone & Joint Surgery (JBJS) and the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), will look at the efficacy of both nonoperative and surgical approaches to basilar thumb arthritis.

  • Co-authors Jorge Villafañe, PT, PhD, and Joshua Cleland, PT, PhD, will discuss results from a randomized trial in JOSPTthat compared a multimodal program of exercise and mobilization to a placebo in the management of basilar thumb arthritis.
  • E.R. Hovius, MD, co-author of a randomized trial in JBJS comparing trapeziometacarpal fusion with trapeziectomy plus ligament reconstruction, will delineate the findings from this Level I study.

Moderated by Sanjeev Kakar, MD, a hand surgeon at the Mayo Clinic in Rochester, Minnesota, the webinar will include additional perspectives from two expert commentators—Krysia Dziedzic, PhD, and Peter Stern, MD.


Click here to register.

JBJS JOPA Image Quiz: 74-Year-Old Woman with Knee Pain

jopa-image-quiz_9_26_16This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 74-year-old woman with a 2-month history of left knee pain. She was given an intra-articular knee injection for presumed osteoarthritis, which failed to provide any relief. At a follow-up visit, clinicians obtained the MRI shown here.

Pick among five possible diagnoses: secondary osteonecrosis, transient osteoporosis, spontaneous osteonecrosis, osteochondritis dissecans, or bone marrow edema lesion.

JBJS Editor’s Choice: HTO Remains Relevant

marc-swiontkowski-2Sport activity continues to increase in priority in modern society. And with a concomitant increase in single-sport focus early in life and near year-round training, the incidence of knee injuries will also continue to increase.  Among surgeons and patients, there has been some waning of interest in high tibial osteotomy (HTO) for the most common form of unicompartmental arthritis because results from   unicompartmental arthroplasty keep improving, but HTO remains an appropriate choice for patients with very high functional demand.

In the September 21, 2016 issue of The Journal, Ekhtiari et al. report on the findings of a well-conducted systematic review on return-to-work and -sport outcomes of HTO. The authors found that more than four-fifths of patients returned to work or sport, usually within a year after surgery. Approximately four-fifths of patients returned to sport at a level equal to or greater than their preoperative level, and among non-military patients included in the review, 97.8% returned to work at an equal or greater level.

As with most systematic reviews in orthopaedic surgery, the basic concern here is with the quality of the literature that forms the basis of the analysis. The vast majority of studies included in the review were Level IV case series, which leads to concerns about selection and detection bias. Those concerns notwithstanding, a return to sport activity of 87% at a mean follow-up of longer than 5 years is remarkable.

We must recognize that patients who wish to return to sport are the most highly motivated population we serve. HTO should not fall off our radar screen of options for patients with high functional demand and medial compartment arthritis, for they can be some of the most satisfied patients we treat.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

JBJS Elite Reviewers


JBJS Reviewers are key to The Journal’s ability to publish the highest quality of evidence-based information, to advance research, and to enhance the quality of care for orthopaedic patients. The JBJS Elite Reviewers Program publicly recognizes our best reviewers for their outstanding efforts. We hope that the Program and its reviewer benefits will encourage all reviewers to aspire to meet the program requirements.

Reviewers who review 4 or more manuscripts per year, rarely decline an invitation to review a manuscript (responding within 48 hours), and complete highly graded reviews within 1 week are eligible for the program. Elite Reviewers receive the following benefits in recognition of their exemplary performance:

  • No submission fees for papers of which the reviewer is the first author (for 12 months)
  • Free CME credits for all reviews
  • Free online access to all JBJS publications
  • A letter to the reviewer’s department head from JBJS Editor-in-Chief, Marc Swiontkowski, MD, recognizing and commending his/her good work
  • Name recognition on the JBJS Elite Reviewers Program Web page and on the masthead of The Journal

For JBJS Consultant Reviewer Guidelines, visit

To learn how you can be a better reviewer visit

Here is the current list of JBJS Elite Reviewers:

Steven P. Arnoczky
George Babis
Ryan Calfee
Antonia F. Chen
Charles Cornell
Charles  Cox
John M. Cuckler
Thomas A. DeCoster
Lawrence Dorr
Freddie H. Fu
H. Kerr  Graham
Greg Guyton
Edward Joseph Harvey
James A. Keeney
Mark C. Lee
Stephen Li
Leisel D. Masson
Michael D. McKee
Omer Mei-Dan
Robert  Pilliar
Matt Provencher
Dino  Samartzis
Andrew Jason Schoenfeld
Edward M. Schwarz
Howard Joel Seeherman
George H. Thompson
Andre  van Wijnen
J. Michael Wiater
David Wong
Adolph J. Yates


Peer Review Week: Day 4

JBJS is helping celebrate Peer Review Week 2016 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2016, JBJS will profile three different top reviewers on OrthoBuzz. The week will culminate with a listing of our current Elite Reviewers.

Today, let’s meet Harry McKellop, Gordon Groh, and Philipp Moroder:

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Harry McKellop, PhD

What do you like best about reviewing for JBJS?
It helps to keep me informed of the latest accomplishments in research; I usually
am able to suggest ways for the authors to improve their manuscripts; in the end,
it is a benefit to the orthopaedic community and the patients.
How do you find time to review for JBJS?
I am a “retired” emeritus professor; but I always considered reviewing
for JBJS as an enjoyable way for giving  back to the profession.
What do you see as JBJS’ role in shaping the future of orthopaedics?
The research and clinical papers provide valuable information and guidelines
for improving the quality of care to the patients.

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Gordon Groh, MD
Mission Health

What do you like best about reviewing for JBJS?
Reviewing offers me the opportunity to “make a bigger impact.” Changing the paradigms for patient care affects entire populations of individuals and improves outcomes for everyone.  JBJS leads the effort to study, report, understand and improve musculoskeletal disease processes, and I am delighted to play a role.
How do you find time to review for JBJS?
Giving back is an inherent part of the contract which each of us is bound to as part of our training process.  Doing the right thing is never easy or convenient, but the rewards always outweigh the inconvenience.
What do you see as JBJS’ role in shaping the future of orthopaedics?
JBJS creates a landscape which is both permanent and evolving.  The Journal creates a permanent electronic record of our current thoughts regarding musculoskeletal disease and produces a template for understanding that which is ever-changing.

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Philipp Moroder, MD
Charitè Universitaetsmedizin, Berlin

What do you like best about reviewing for JBJS?
The JBJS is a top-notch Journal which features high-quality manuscripts. Additionally, the editorial staff is great and puts
a lot of effort into even further improving the content quality.
How do you find time to review for JBJS?
Even though my schedule is pretty busy, I try my best to “fit-in” the JBJS reviews since to me it is a great honour to serve as a reviewer for
the JBJS.
What do you see as JBJS’ role in shaping the future of orthopaedics?
JBJS is probably one of the orthopaedic journals with  the most “clinical
impact.”Due to its high publication standards and excellent content,
it is a great source for information on what is new in the field of orthopedics
and offers ideas and solutions for the improvement of our daily patient care.

Peer Review Week: Day 3

JBJS is helping celebrate Peer Review Week 2016 by formally recognizing some of its top reviewers for their contributions. Each day during Peer Review Week 2016, JBJS will profile three different top reviewers on OrthoBuzz. The week will culminate with a listing of our Elite Reviewers for the first half of 2016.

Today, let’s meet Chad Mather, Carola van Eck, and David Kovacevic:

Dr. chad mathers iii.jpg
Chad Mather, MD
Duke Health

What do you like best about reviewing for JBJS?
I always look forward to reviewing articles for JBJS as they are always interesting
and related to my area of expertise.The articles are typically well written so I
am able to focus on the quality of the methods and direction of the discussion.
This makes it an enjoyable and stimulating experience.
How do you find time to review for JBJS?
It is a challenge but I usually read them while riding my indoor cycle.
The two work together to keep me fit and not too far behind in my reviews!
What do you see as JBJS’ role in shaping the future of orthopaedics?
Impact factor aside, JBJS is the most credible and prestigious orthopaedic
journal.  Articles published in JBJS will always be highly read, cited and respected.
JBJS has a role in not only ensuring the scientific methods are correct
but also to choose articles that lead our field into the future.

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Carola van Eck, MD
Kerlan Jobe Orthopaedic Clinic

What do you like best about reviewing for JBJS?
I love that I could be the first person reading about the latest and greatest
breakthroughs in orthopaedic surgery.
How do you find time to review for JBJS?
Peer reviewing is fun, but can take a substantial amount of time. Luckily,
you get faster at it as you gain more experience. Usually I find time
between my cases to work on peer reviews.
What do you see as JBJS’ role in shaping the future of orthopaedics?
I believe JBJS continues to be a top journal in the field of orthopaedics. Its
Impact Factor has consistently been amongst the highest in the field,
proving the journal will have a huge role in shaping the future or orthopaedics.

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David Kovacevic, MD
Yale University

What do you like best about reviewing for JBJS?
Opportunity to review manuscripts that have the potential to change the way we practice orthopaedics.
How do you find time to review for JBJS?
It is a privilege to be a reviewer for the leading orthopaedic journal in the world so finding time to help the section editors is a top priority.
What do you see as JBJS’ role in shaping the future of orthopaedics?
Providing orthopaedic surgeons and musculoskeletal providers with the best evidence-based medicine by integrating basic science research with clinical expertise to enhance patient outcomes.