Archive | October 2017

How “Conflicted” Are Medical Journal Editors?

Open Payments Logo for OBuzzMedical journal editors wield substantial power in deciding what gets published and potentially implemented in clinical practice. Theoretically, those decisions could be influenced by “commercial” relationships. To help ascertain the extent of such relationships, a recent retrospective observational study in the BMJ examined payments by US pharmaceutical and device manufacturers to 713 editors from 52 influential medical journals in 26 specialties, including orthopaedics.

Using data from the Open Payments database from 2014 and information gleaned from a survey of journal editors-in-chief, Liu et al. discovered the following:

  • Among 713 editors, 50.6% received some “general payments” (i.e, money deposited directly into personal bank accounts) from pharmaceutical or medical device manufacturers in 2014.
  • The median general payment to journal editors was $11, while the mean general payment was $28,136.
  • The highest median payments were found among journal editors in the specialties of endocrinology ($7,207), cardiology ($2,664), gastroenterology ($696), rheumatology ($515), and urology ($480). The median payment among orthopaedics editors was $121.
  • The two highest payments to individual editors were >$1 million, and those editors were in the specialties of cardiology and—you guessed it—orthopaedics.

Beyond the dollar-and-cents data, the authors discovered that only one-third of the 52 journal websites had readily accessible statements of conflict-of-interest (COI) polices. Among the journals with COI policies, 75% said they have formal recusal processes that exclude an editor from handling manuscripts where he/she has a conflict.

According to an accompanying appendix, among the 34 JBJS editors included in the analysis (i.e., the US-based editor-in-chief, deputy editors, and associate editors), six had received general payments >$50,000 in 2014. The JBJS COI statement asserts that if conflicts are disclosed that might affect an editor’s ability to adjudicate a manuscript fairly, “the paper will be reassigned to another editor.” It also states that “the Editor-in-Chief has no known conflicts of interests or competing interests and makes the final decision regarding acceptance or rejection of all manuscripts submitted.”

In Spinal-Metastasis Surgery, High-Volume Yields Better Outcomes

Spinal Metastasis for OBuzzIn orthopaedics, the connection between a hospital/surgeon performing a surgical procedure many times and improved outcomes has been demonstrated compellingly with total joint replacement. In the October 18, 2017 edition of JBJS, Schoenfeld et al. show that this same volume-outcome relationship holds true in the surgical treatment of spinal metastases.

The study analyzed 3,135 patients treated by 1,488 surgeons at 162 hospitals throughout Florida. Using sophisticated statistics, the authors defined high-volume surgeons as those who had performed ≥49 procedures per year and high-volume hospitals as those at which ≥167 procedures per year had been performed.

Among the entire cohort, the 90-day complication rate was 26% and the readmission rate was 43%. (Rates that high are not unexpected with such risky spinal surgeries.) Here are the findings according to surgeon volume:

  • 21% complication rate for patients treated by high-volume surgeons
  • 30% complication rate for patients treated by low-volume surgeons
  • 37% readmission rate for patients treated by high-volume surgeons
  • 47% readmission rate for patients treated by low-volume surgeons

In other words, the relative odds of complications and readmissions following operations performed by low-volume surgeons were approximately 40% higher than those following operations done by high-volume surgeons. A similar percentage difference was found between the odds at low- and high-volume hospitals. In a secondary analysis, the authors found that African Americans and Hispanics were significantly less likely than white patients to receive care from a high-volume surgeon or at a high-volume hospital.

Schoenfeld et al. state that the ideal care for patients facing surgery for spinal metastases comes from a team of experienced surgeons, medical oncologists, radiation oncologists, nurses, and support staff. They conclude that their findings “speak to the need for regionalization of subspecialty spinal oncology care as a means to optimize treatment for this cohort of patients.”

“Phenotype” Redefined in Osteoarthritis Research

Osteoarthritis for BSTOTWThis basic science tip comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Over the decades, the meaning of the term “phenotype” has changed. In the past it was solely applied to inherited disorders and was based on physical appearance or clinical presentation. Similarly, the term “penetrance” was applied to the variations in phenotype severity relative to normal. Over time, it has been found that penetrance is usually a reflection of different mutations for the same gene at different parts of the allele, or a mutation in one of several specific genes that could contribute to a similar phenotype.

Now, both terms have been applied to a variety of genetic and environmental circumstances that may affect physical appearance and function. In osteoarthritis research, the term “phenotype” has increasingly been used to define physical, genetic, environmental, and other variables, both past and present.

The authors of a recent abstract use a modern application for the term phenotype to systematically review the literature for studies using knee characteristics relevant for phenotyping osteoarthritis (OA).1 A comprehensive search was performed limited to observational studies of individuals with symptomatic knee OA that identified phenotypes based on OA characteristics, and then the authors assessed phenotypic association with clinically important outcomes.

Based on their abstract, 34 of 2777 citations were included in a descriptive synthesis of the data. Clinical phenotypes were investigated most frequently, followed by laboratory, imaging, and etiologic phenotypes. Eight studies defined subgroups based on outcome trajectories (pain, function, and radiographic progression). Most studies used a single patient or disease characteristic to identify subgroups, while five included characteristics from multiple domains.

Evidence from multiple studies suggested that pain sensitization, psychological distress, radiographic severity, BMI, muscle strength, inflammation, and comorbidities are associated with clinically distinct phenotypes. Gender, obesity and other metabolic abnormalities, the pattern of cartilage damage, and inflammation may delineate distinct structural phenotypes. However, only a few of the 34 studies reviewed investigated the external validity of the chosen phenotypes or their prospective validity using longitudinal outcomes.

While the authors remarked on the heterogeneity of the data included in studies investigating knee OA phenotypes, they say that the phenotypic characteristics identified in their review could form a classification framework for future studies investigating OA phenotypes.

It should be noted that the FRAX score used to calculate fragility fracture risk could be considered a phenotypically based system, the validation of which is continuing.

Reference

  1. Deveza LA, Melo L, Yamato TP, Mills K, Ravi V, Hunter DJ. Knee osteoarthritis phenotypes and their relevance for outcomes: a systematic review. Osteoarthritis 2017 Aug 25. pii: S1063-4584(17)31156-1. doi: 10.1016/j.joca.2017.08.009. [Epub ahead of print].

What’s New in Hip Replacement 2017

THA for OBuzzEvery 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, James T. Ninomiya, MD, MS, lead author of the September 20, 2017 Specialty Update on Hip Replacement, selected the five most clinically compelling findings from among the more than 50 studies covered in the Specialty Update.

Obesity and THA Outcomes
–Obesity is a well-established risk factor for perioperative THA complications. A prospective registry-based study found that reoperation and implant revision or removal rates increased with increasing BMI. More specifically, increasing BMI was associated with increased rates of early hip dislocation and deep periprosthetic infection.

Infection Prevention
–Two studies 1, 2 demonstrated that patients who have intra-articular injections within 3 months prior to THA experienced nearly double the risk of periprosthetic infection in the first postoperative year, compared with those in noninjection control groups.

Surgical Approaches to THA
–A study of >2,100 patients revealed that, despite claims to the contrary, there were no differences in dislocation rates between those who underwent THA using the direct anterior approach and a propensity-score matched cohort who underwent THA using a posterior approach.3

OR Temperature
–What is the optimal temperature for an orthopaedic operating room? Anecdotes are often used to justify keeping operating rooms at uncomfortably high temperatures, which leads to discomfort and fatigue for members of the surgical team. A comprehensive literature review led authors to suggest that preoperative patient warming, intraoperative patient warming with forced-air devices, and keeping OR temperature at ≤19° C is the ideal combination for comfort while still maximizing patient safety and outcomes.

Return to Driving
–Following joint replacement, patients often ask when it will be safe to return to driving. A meta-analysis of 19 studies concluded that the mean time for return to baseline reaction time for braking was 2 weeks following a right-sided hip replacement and 4 weeks following a right-sided knee replacement.4 The authors stressed, however, that return-to-driving recommendations should be individualized for each patient.

References

  1. Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):166–169.e1. Epub 2016 Apr 22.
  2. Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016 ;31(4):820–3. Epub 2015 Sep 1.
  3. Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty. 2016 ;31(9)(Suppl):127–30. Epub 2016 Mar 15.
  4. van der Velden CA, Tolk JJ, Janssen RPA, Reijman M. When is it safe to resume driving after total hip and total knee arthroplasty? A meta-analysis of literature on post-operative brake reaction times. Bone Joint J. 2017 ;99-B(5):566–76.

Webinar—Patient-Centered Treatment of Clavicle Fractures

pic of Nov speakers to use

Clavicle fractures are among the most common injuries treated by orthopaedists. Until 2005, no matter the amount of displacement, standard treatment was immobilization for a few weeks, followed by gradually increased activity until the fracture healed. In 2007, Dr. Mike McKee published a landmark article in JBJS that concluded that clavicle fractures with displacement greater than 100% had better outcomes if treated with open reduction and internal fixation (ORIF). Since that time, numerous studies have re-examined this question, some supporting Dr. McKee’s 2007 findings, and some disputing them.

On November 15, 2017 at 7 PM EDTJBJS will join with JSES (Journal of Shoulder and Elbow Surgery) to present a webinar looking at the current paradigm for treating  clavicle fractures. Moderated by Dr. William Mallon, editor-in-chief of JSES, the webinar will focus on two recent clavicle-fracture papers:

  • Dr. Philip Ahrens will discuss his recent JBJS paper, “The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures.”
  • Dr. Brian Feeley will discuss his 2016 JSES paper, “Plate Fixation of Midshaft Clavicular Fractures: Patient-Reported Outcomes and Hardware-Related Complications.”

After each author presentation, expert commentary will be provided. Discussing Dr. Ahrens’ paper will be Dr. Michael McKee, recently named chairman of orthopaedics at the University of Arizona. Dr. Gus Mazzocca, chairman of orthopaedics at the University of Connecticut, will comment on Dr. Feeley’s paper. The webinar will then be open to addressing viewer-submitted questions for the authors and the commentators.

Seats are limited, so register now!

 

Has Conventional Polyethylene Become Obsolete in THA?

XLPE for OBuzzHighly cross-linked polyethylene (XLPE) has been in clinical use for nearly 15 years. In acetabular components for total hip arthroplasty (THA), XLPE’s superior wear characteristics and lower revision rates, relative to conventional polyethylene (PE), have been demonstrated in numerous studies. Here is one more: a 10-year Level I study in the October 18, 2017 issue of The Journal of Bone & Joint Surgery by Devane et al.

In this double-blinded, randomized trial, authors measured 2-D, 3-D, and volumetric wear (in mm or mm2), along with wear rates (mm/year), presence or absence of osteolysis, and revision rates in 91 patients at specified time intervals, up to a minimum of 10 years. The following results corroborate the general findings from most other studies on this topic:

  • The mean 3-D wear rate among patients with the XLPE acetabular liner was 0.03 mm/yr, versus 0.27 mm/yr among patients with conventional PE.
  • Eight percent of patients in the XLPE group showed radiographic evidence of osteolysis, versus 38% of patients in the PE group.
  • Patients with the conventional PE liner had a significantly higher revision rate (14.6%) than those with the XLPE liner (1.9%).

There were no significant between-group differences in clinical outcome scores, including the Oxford Hip Score and SF-12 physical well-being score.

The authors note that “the longer-term implications of these findings are unclear,” but their calculations indicated that, through 20 years, none of the XLPE liners would wear through, but 6 of the conventional PE liners would require revision due to wear-through.

Long-term Results Show No Advantage to “Minimalist” THA

Minimal Incision THA for OBuzzThe debate regarding minimally invasive/minimal incision total hip arthroplasty (THA) has been simmering for a decade and a half. When assessing the impact of adult reconstruction procedures, patients and treating physicians alike are most interested in longer-term results. Improved return of function in the first 3 to 6 weeks is of some value to all patients—and perhaps of great value to younger patients—and that has been one of the purported advantages of the “minimalist” approach. But it is the long-term results that really matter.

In the October 18, 2017 issue of The Journal, Stevenson et al. provide 10-year results from a 2005 randomized trial of small-incision posterior hip arthroplasty, and they confirm it adds no clinical, radiographic, or implant-survivorship benefit when compared with a standard posterior approach. An extra caveat here is that these procedures, originally done in 2003-2004, were undertaken by a highly experienced surgeon who had performed >300 minimal-incision THAs. In the hands of surgeons with less experience, smaller incisions may result in suboptimal component positioning and other complications, a point emphasized by Stevenson et al. and by Daniel Berry in his JBJS editorial accompanying the original study.

This long-term data is of great value to patients and surgeons alike. It is my hope that such high-quality evidence will temper the claims used in marketing materials that hype minimally invasive approaches, to which hip surgeons are routinely subjected.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

More Efficient Orthopaedic Education Needed

WI Banner for OBuzz

The October 4, 2017 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Drs. Peter Scoles and Shepard Hurwitz.

The authors suggest that integration of medical school curricula with the first year of postgraduate training is a practical approach to improving efficiency and reducing costs to both doctors in training and the academic medical centers that help train them. In explaining specific ways to change the paradigm for training orthopaedic surgeons, the authors conclude that an integrative approach would accelerate the process for qualified candidates, while lowering costs and ensuring adequate training opportunities for all.

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

With OCA, Don’t Fret About Condyle Matching

OCA for OBuzz

Osteochondral allograft transplantations (OCAs) are becoming a mainstay of treatment for knee-cartilage injuries. To help ensure that the allograft plug is transplanted with <1 mm of step-off from the surrounding recipient cartilage, many surgeons restrict themselves to orthotopic OCAs—matching the graft-recipient condyles in a lateral-to-lateral or medial-to-medial fashion.

However, in the October 4, 2017 issue of The Journal of Bone & Joint Surgery, Wang et al. demonstrated that both orthotopic and non-orthotopic (e.g., lateral condyle-to-medial condyle) OCA resulted in significantly improved outcomes in 77 cases followed for a mean of 4.3 years. The authors found that reoperation rates and pre- and postoperative scores in physical functioning and pain did not differ significantly between the orthotopic (n=50) and non-orthotopic (n=27) groups. These results suggest that condyle-specific matching may not be necessary.

One problem with orthotopic OCA is that 75% of the available allograft is supplied in the form of lateral condyles, while most full-thickness cartilage lesions presenting for treatment occur in the medial condyle. Consequently, surgeon preferences for orthotopic OCA limit the number of available matches and lead to an estimated 13% of available grafts being discarded.

Noting that many factors contribute to successful resurfacing of cartilage defects in the knee, the authors say that “it may be overly simplistic to assume that a conventionally matched orthotopic allograft will ensure a smooth surface contour at the recipient site.” They go on to conclude that “if surgeons forewent condyle-specific matching, more allografts would be readily available, which would shorten wait times, provide fresher grafts with increased chondrocyte viability, and lower procedure costs.”

Aggressive Treatment Improves QOL in Many Cases of Spinal Metastases

swiontkowski marc colorA significant portion of metastatic disease comes with no clear identification of a primary tumor; this is unfortunately the case with many spinal metastases. In the October 4, 2017 issue of The Journal, Ma et al. evaluate the survival and patient-reported quality-of-life (QOL) outcomes for patients with spinal metastases from cancer of unknown primary origin.

Their prospective longitudinal study confirms that a more aggressive strategy that combines surgery and radiation therapy results in better QOL (as measured with the four-domain FACT-G instrument) than radiation alone. There was no significant difference in survival time between the two groups. In a subgroup analysis of patients receiving surgery, those who underwent circumferential decompression had significantly better functional and physical well-being and higher total QOL scores than those who underwent decompressive laminectomy.

These findings emphasize the critical role of shared decision making in such difficult situations. A dire diagnosis with poor statistical chances of long-term survival does not mean that patients should not be informed of treatment options and have the opportunity to opt for an aggressive surgical approach, especially if that decision is likely to result in improved QOL. Let us endeavor to compassionately provide patients with the facts, as we understand them, and let them select from among the medical and surgical options that are at their disposal. More often than not, in this sad scenario, it seems aggressive is better in terms of quality of life.