JBJS Essential Surgical Techniques (EST) is pleased to congratulate the winners of its two Editor’s Choice Awards for 2016:
The award for best technique article went to Austin T. Fragomen, MD and S. Robert Rozbruch, MD for Lengthening of the Femur with a Remote-Controlled Magnetic Intramedullary Nail.
The recipients of the best Key Procedures video award were Jesse D. Chlebeck, MD; Christopher E. Birch, MD; and Jennifer W. Lisle, MD for Percutaneous in Situ Fixation of Slipped Capital Femoral Epiphysis.
Click here to learn about the 2017 EST Editor’s Choice competition.
Get the answer to that question and many more in the 2016 Salary and Call Survey, compiled by JOPA, the JBJS Journal of Orthopaedics for Physician Assistants.
In addition to a US regional breakdown of average base salaries among PAs working in orthopaedics, the 2016 survey contains accurate, trending information from PAs about:
- Hospital versus Private-Practice Salaries
- Trends in Bonuses, Benefits, and Perks
- Workload and Autonomy
- Call Structures and Schedules
- Job Satisfaction
The survey was conducted by email during November and December 2016. JBJS Journal of Orthopaedics for Physician Assistants (JOPA) sent an online survey to 3,056 JOPA subscribers. Three-hundred twenty (320) physician assistants in orthopaedics responded, representing a response rate of 10%. At a 95% confidence level, results are projected at a ±5.5% margin of error.
Reverse total shoulder arthroplasty (RTSA) has yielded promising medium-term outcomes, but what about longer-term results? In the March 15, 2017 edition of The Journal, Bacle et al. look at patient outcomes, prosthetic survival, and complications after a mean follow up of 12.5 years.
The good-news finding from this study was that the overall prosthetic survival rate (using revision as the end point) was 93%, confirming the reliability of the Grammont-style prosthesis. Time, however, took its toll on other outcomes. For example, both mean and absolute Constant scores among the cohort decreased significantly compared with the scores at the medium-term follow up (a minimum of 2 years). The cumulative long-term complication rate was 29%, with 10 of the 47 complications occurring at a mean of 8.3 years. Seven of those 10 delayed complications were attributed to mechanical loosening.
The authors suggest that the deterioration of RTSA outcomes seen in this study “is probably related to patient aging coupled with bone erosion and/or deltoid impairment over time.” They conclude that long-term RTSA outcomes “may be impacted by both the etiology of the shoulder dysfunction and the time since implantation.”
For more peer-reviewed content related to RTSA from JBJS Essential Surgical Techniques, click on the following links:
- Patient-Matched Implementation for Reverse Total Shoulder Arthroplasty
- Glenoid Bone-Grafting in Revision to a Reverse Total Shoulder Arthroplasty: Surgical Technique
- Technique for Reverse Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis with a Biconcave Glenoid
Every month, JBJS publishes a Specialty Update—a review of some of the most pertinent and impactful studies published in one of 13 orthopaedic subspecialties during the previous year. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 15, 2017 Specialty Update on hand and wrist surgery, to select five of the most clinically compelling findings from among the more than 40 he cited in the article.
Carpal Tunnel Syndrome
—The AAOS published updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome (CTS). Among the conclusions are the following:
- Thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out.
- High body mass index and repetitive hand and wrist actions are associated with an increased risk of developing CTS.
- Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment.
- There is no benefit to routine postoperative immobilization after CTS surgery.
—If a distal radius fracture is displaced, especially in an elderly patient, should one proceed with nonoperative or operative treatment? A systematic review/meta-analysis1 involving more than 800 patients 60 years of age or older found that operatively treated patients had greater grip strength and better restoration of radiographic parameters than nonoperatively treated patients. However, those who underwent surgery also experienced more complications (primarily hardware-related) that required surgery.
Thumb and Digit Arthritis
—There are a myriad of treatments for the management of basilar thumb arthritis, ranging from trapeziectomy to fusion. Which one is better, especially if the scaphotrapeziotrapezoid joint is not involved? A prospective study was conducted randomizing women older than 40 with basal thumb joint arthritis to trapeziectomy and suspension arthroplasty or carpometacarpal joint arthrodesis. After a mean follow-up of 5.3 years, those in the trapeziectomy-suspension arthroplasty group had significantly better pain reduction and function.2 Researchers halted the study prematurely due to increased complications in the arthrodesis group.
Outcome Measurement Tools
—Among the many patient-reported outcome measures for the upper extremity, which should be used for which conditions? For distal radius fractures, a systematic approach has been proposed3 that captures outcomes across five domains: range of motion and grip strength, patient-reported scores of disability and function, complications, pain, and radiographs.4
—Is there any way to make the collection of patient-reported outcomes easier and less time-consuming? An assessment that compared two forms of computerized adaptive tests (CATs) with the DASH (Disabilities of the Arm, Shoulder and Hand) measure among 379 hand-clinic patients found that the CAT required fewer questions to complete than the DASH, yet maintained excellent reliability.5
- Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients. A systematic review and meta-analysis. J Hand Surg Am. 2016 ;41(3):404–13. Epub 2016 Jan 20.
- Spekreijse KR, Selles RW, Kedilioglu MA, Slijper HP, Feitz R, Hovius SE, Vermeulen GM. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a 5-year follow-up. J Hand Surg Am. 2016 ;41(9):910–6.
- Teunis T, Ring D. Comprehensive outcome assessment after distal radius fracture. J Hand Surg Am. 2016 ;41(8):e257. Epub 2016 Jun 11.
- Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Distal Radius Outcomes Consortium. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565–73.
- Beckmann JT, Hung M, Voss MW, Crum AB, Bounsanga J, Tyser AR. Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test. J Hand Surg Am. 2016 ;41(7):739–744.e4. Epub 2016 Jun 3.
When surgeons and patients discuss what treatment will work best for a particular musculoskeletal ailment, they often rely on both “subjective” and “objective” outcome data from previously published assessments. Reviewing both types of data is a good idea, because a study among more than 100 patients with shoulder osteoarthritis by Matsen et al. in the March 1, 2017 issue of The Journal of Bone & Joint Surgery found poor correlation between objective measures of active abduction and subjective patient self-assessments using the Simple Shoulder Test (SST).
The authors used a statistical method called “coefficient of determination”
to confirm “a highly variable relationship” between the patient-reported SST (subjective) and motor-sensor range-of-motion (objective) measurements. In less statistical language, many of the shoulders had good motion and poor self-assessed function, while others had poor motion and good self-assessed function.
The findings led the authors to conclude that “studies of treatment outcomes should include separate assessments of these 2 complementary aspects of shoulder function.” That conclusion was seconded and expanded upon in a commentary by Jeffrey S. Abrams, MD, who wrote that “either [subjective or objective] assessment used independently may lead to the wrong impression.”
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 by clicking on the “Leave a Comment” button in the box to the left.
Even before hand surgery became a specialty, the characteristics of the thumb that enabled pad-to-pad opposition (and therefore fine motor function) were well-recognized: shorter length, fewer bony segments, and pronated position relative to the fingers; a wide first web space; and intrinsic muscle control of abduction, rotation, and pinch. Although these principles were used to devise surgical procedures to restore thumb function prior to Buck-Gramcko’s landmark JBJS article in 1971, most were used for a small number of patients, with limited information available about outcomes. Thumb absence is uncommon, and no hand surgeon was able to gain sufficient experience with index pollicization to refine and enhance the technique until the confluence of Buck-Gramcko’s exceptional skill and one of the major medical catastrophes of the 20th century.
Dieter Buck-Gramcko was born in Hamburg, Germany in 1927. Following World War II, he trained in general and trauma surgery and became one of the first hand surgeons in Germany.1 Between 1957 and 1962, thalidomide was marketed in Germany as a sedative, but it also inhibited angiogenesis, causing limb malformations, including thumb deficiency, when fetuses were exposed to the drug during limb development.2 The resulting large number of German infants with thumb deficiency provided Buck-Gramcko with the opportunity to modify the technique of index pollicization and study the outcomes of his modifications to improve results. He described his findings and results in this landmark article.
His careful description of index pollicization includes the principles and techniques that remain the hallmarks of this operation. His diagram of reduction of bones and joints (Figure 3 of his classic article, shown below) is a simple and elegant depiction of the principles of this complex operation. His rigorous follow-up, measurement of outcomes, and propensity to criticize his own work to improve results are all apparent in this article, which provides an excellent example of applying the scientific method. Not surprisingly, Buck-Gramcko remained rigorous and objective throughout his long career; 20 years later, he published another article focused on complications and poor outcomes after index-finger pollicization.3
Index pollicization is one of the paramount operations of hand surgery, largely because Buck-Gramcko applied theoretical principles of thumb function, methodically and meticulously refined the technique of pollicization, studied the outcomes of his work, and passed this valuable information along in this classic article. It remains a useful guide to the performance of this operation almost half a century later. The thalidomide tragedy had a silver lining, thanks to Buck-Gramcko’s surgical skills, methodologic rigor, and scientific objectivity.
Michelle A. James, MD
JBJS Deputy Editor
- Hoffmann R, Lubahn JD. First Hand: Dieter Buck-Gramcko. Journal of Hand Surgery. 2013;38(5):988-90.
- Stephens T, Brynner R. Dark remedy: the impact of thalidomide and its revival as a vital medicine. Basic Books, N.Y.; 2009.
- Buck-Gramcko D. Complications and bad results in pollicization of the index finger (in congenital cases). Annales de Chirurgie de la Main et du Membre Supérieur 1991;10 (6):506-512).
Spinal epidural hematoma is a rare condition. Because the etiology is often unclear and the medical history is frequently innocuous, a high index of suspicion is required in order to maximize the chances of a successful outcome.
This month’s “Case Connections” spotlights 4 cases of spinal epidural hematoma involving 2 elderly women, a male Olympic-caliber swimmer, and a preadolescent boy.
In the springboard case, from the March 22, 2017, edition of JBJS Case Connector, Yamaguchi et al. report on a 90-year-old woman with a history of transient ischemic attacks (TIAs) and combined aspirin-dipyridamole therapy in whom a large spontaneous spinal epidural hematoma (SSEH) developed rapidly after she shifted her position in bed. The authors concluded that their case emphasized that “early diagnosis of an SSEH and prompt surgical intervention can avoid catastrophic and permanent neurological deterioration and compromise.”
Three additional JBJS Case Connector case reports summarized in the article focus on:
- An 82-year-old woman who developed an epidural hemorrhage and acute paraplegia following vertebroplasty
- A 22-year-old male collegiate swimmer who underwent an emergent operative spinal decompression procedure within 4 hours after presentation to the ED with searing back pain and decreased leg strength
- A 12-year-old boy who presented to the hospital with intense back pain along with numbness, tingling, and loss of motor function in the lower extremities 3 weeks after he had been pushed into a wall at school
Among the take-home points from this “Case Connections” article: MRI is the gold standard for the diagnosis of spinal epidural hematomas, and treatment typically involves operative decompression consisting of laminectomies and evacuation of the hematoma.
In the March 15, 2017 issue of The Journal, Johns et al. report results from a Level III cohort study comparing arthroscopic vs open irrigation for control of acute native-knee sepsis. The authors collected information on more than 160 patients with knee sepsis over a 15-year period, which is a large cohort of patients with this relatively unusual clinical problem.
The data show a cumulative success rate of 97% with arthroscopic treatment after 3 irrigations and debridements vs 83% success in the arthrotomy group after the same number of procedures—a clinically important difference. Significantly fewer arthroscopic procedures were required for successful treatment, relative to open procedures, and post-procedure median knee range of motion was significantly greater in the arthroscopic group (90°) than in the open treatment group (70°).
The fact is that arthroscopic instruments allow a greater volume of irrigation fluid to be instilled with better access to the posterior recesses of the knee. With an open arthrotomy, it is more difficult to irrigate with high volumes, and the posterior recesses of the knee are not well accessed. It seems clear that arthroscopic management of acute knee sepsis should be the standard of care for these reasons, as well as because the technique is minimally invasive in terms of soft tissue stripping and incision size.
Treating infections of major-weight bearing joints is following a trend seen in surgical management of many orthopaedic conditions—smaller exposures with use of adjunctive visualization techniques.
Marc Swiontkowski, MD
During the 2017 AAOS Annual Meeting in San Diego next week, JBJS will formally recognize its 30 Elite Reviewers.
In the days leading up to the Annual Meeting, we would like to profile and thank some of our additional outstanding reviewers. Today, let’s meet Peter Stern and Kevin Garvin:
Peter Stern, MD
University of Cincinnati
What do you like best about reviewing for JBJS?
Expands my knowledge base and permits me to participate in a activity which I believe is paramount to broadening the orthopedic peer reviewed knowledge base.
How do you find time to review for JBJS?
I make the time on the weekend. Get up early.
What do you see as JBJS’ role in shaping the future of orthopaedics?
It’s the #1 peer-reviewed journal and provides accurate msk information in
many domains such as JBJS, JBJS Reviews, the virtual recertification course, Case Connector, etc.
Kevin L. Garvin, MD
Nebraska Medical Center
What do you like best about reviewing for JBJS?
The opportunity to review cutting edge research and hopefully
help improve the clarity of the research.
How do you find time to review for JBJS?
I just make time for doing the reviews.
What do you see as JBJS’ role in shaping the future of orthopaedics?
One of the leading media for communicating new research.
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, Derek Kelly, MD, co-author of the February 15, 2017 Specialty Update on Pediatric Orthopaedics, selected the five most clinically compelling findings from among the 60 studies summarized in the Specialty Update.
—A systematic review of eight randomized studies comparing splinting with casting for distal radial buckle fractures confirmed that splinting was superior in function, cost, and convenience, without an increased complication rate.1
—A review of the treatment of 361 pediatric diaphyseal femoral fractures before and after the 2009 publication of AAOS clinical guidelines for treating such fractures revealed that the guidance had little impact on the treatment algorithm in one pediatric hospital.
—Bracing remains an integral part of managing adolescent idiopathic scoliosis, but patient compliance with brace wear is variable. A prospective study of 220 patients demonstrated that physician counseling based on compliance-monitoring data from sensors embedded in the brace improved patients’ average daily orthotic use.
—AAOS-published evidence-based guidelines on the detection and nonoperative management of developmental dysplasia of the hip (DDH) in infants from birth to 6 months of age determined that only two of nine recommendations gleaned from evidence in existing literature could be rated as “moderate” in strength:
- Universal DDH screening of all newborn infants is not supported.
- Imaging before 6 months is supported if the infant has one or more of three listed risk factors.
Seven additional recommendations received only “limited” strength of support.
—A study of the utility of inserting an intraoperative intracranial pressure (ICP) monitor during closed reduction and pinning for slipped capital femoral epiphysis (SCFE) found that 6 of 15 unstable hips had no perfusion according to ICP monitoring. However, all 6 hips were subsequently reperfused with percutaneous capsular decompression, and no osteonecrosis developed over the next 2 years.
- Hill CE, Masters JP, Perry DC. A systematic review of alternative splinting versus complete plaster casts for the management of childhood buckle fractures of the wrist. J Pediatr Orthop B. 2016 ;25(2):183–90.