Archive | January 2018

JBJS 100: Cuff Tear Arthropathy and Cervical Spine Disorders

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Cuff Tear Arthropathy
Neer CS 2nd, Craig EV, Fukuda: JBJS, 1983 Dec; 65 (9): 1232
These authors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition.

The Treatment of Certain Cervical-spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion
Smith GW, Robinson RA: JBJS, 1958 June; 40 (3): 607
Dr. Robinson’s technique has the support of biomechanical principles, which makes this particular approach and bone-graft fusion construct inherently stable. The versatile approach is utilized for all sorts of anterior procedures, including removal of intervertebral discs, arthrodesis, and vertebrectomy.

Latest JBJS Video Summary

Techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. New video summary available: http://bit.ly/2DN3JNr

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Latest JBJS Infographic

Next-generation sequencing is a well-established technique for sequencing of DNA and has recently gained attention in many fields of medicine.

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Prosthetic Metal Allergies: The Mystery Continues

Metal Hypersensitivity for OBuzzThis 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.

Immunosensitivity to metallic implants has been recognized for years, with the principal research focus on joint arthroplasty components. While cutaneous metal allergies are relatively common (as prevalent as 20%), immunosensitivity to implanted metal is much less common.

On their own, metal ions in the body such as nickel and cobalt do not cause immune responses, although high levels can be toxic to specific organs. However, when these ions associate with proteins in the plasma they may form haptens. These molecules in turn may bring about delayed hypersensitivity reactions.

Reactions to metals appear to be type IV (delayed) hypersensitivity responses leading to activation of T-lymphocytes, which in turn release inflammatory cytokines. While Langerhans cells in skin respond to direct or indirect antigen presentation, we don’t know which cells are involved in intra- and extra-articular manifestations in total joint arthroplasty. The skin response may include eczematous and/or erythematous papular lesions; within the affected limb, pain, swelling, and stiffness may be regional responses.

Determining cause and effect remains problematic. We have not yet conclusively determined whether symptoms from joint implants are due to metal sensitivity.  The diagnosis of metal immunosensitivty is based on exclusion of complications such as infection, aseptic loosening, mechanical malalignment, and, less commonly, complex regional pain syndrome and overstuffing.

The two most utilized tests for implant metal allergies are cutaneous patch testing and lymphocyte transformation testing. Unfortunately, cutaneous testing may not reflect the process in the joint, and preoperative patch screening has not proven to be beneficial. Lymphocyte transformation testing is expensive, not validated, and unavailable for many.

Alternatives include use of implants coated with titanium nitride, zirconia nitride, or zirconium oxide, or the use of “hypoallergenic” metals such as titanium and oxinium. However, except in the setting of revision, the clinical and cost effectiveness of these metals remain to be confirmed. The one relative certainty related to this issue is to use alternative-metal implants in patients with known severe systemic or cutaneous metal sensitivity.

References

Nima Eftekhary, MD; Nicholas Shepard, MD; Daniel Wiznia, MD; Richard Iorio, MD; William J. Long, MD, FRCSC; and Jonathan Vigdorchik, MD. Metal Hypersensitivity in Total Joint Arthroplasty https://icjr.net/articles/metal-hypersensitivity-in-total-joint-arthroplasty

Arif Razak, BSc, MBChB, MRCS; Ananthan D. Ebinesan, MBChB, MRCS; Charalambos P. Charalambous, BSc, MBChB, MSc, MD, FRCS (Tr & Orth). Metal Hypersensitivity in Patients with Conventional Orthopaedic Implants. JBJS Reviews; 2014 Feb 4; 2 (2).10.2106/JBJS.RVW.M.00082

Webinar on Feb. 12—Surgical Approaches to Hip Replacement

Feb Webinar speakers for OBuzzEvery surgical approach to total hip arthroplasty (THA)—posterior, anterior, or lateral and conventional or minimally invasive—has adherents and critics. Despite scores of published studies comparing these different approaches, no single best practice has yet emerged.

On Monday, February 12, 2018 at 6:30 PM EST, JBJS will present a complimentary* webinar that addresses this ongoing debate with recent evidence about five different surgical approaches to THA. Moderated by James Waddell, MD, former President of the Canadian Orthopaedic Association, the webinar will springboard off two JBJS articles:

  • Knut Erik Mjaaland, MD will discuss a registry study that found no significant 5-year outcome differences among four different approaches: two minimally invasive (anterior and anterolateral), and two conventional (posterior and direct lateral).
  • R. Michael Meneghini, MD will explain why his group concluded that the direct anterior approach may confer a greater risk of early femoral component failure due to aseptic loosening, compared with the direct lateral or posterior approaches.

After the authors’ presentations, Anthony Unger, MD and Tad Mabry, MD will add clinical perspectives to the current state of this important research. During the last 15 minutes of the webinar, panelists will answer questions from the audience.

Space is limited, so Register Now.

* This webinar is complimentary for those who attend the event live and will continue to be available for 24 hours following its conclusion.

No Harm When Residents Are Involved in Hip-Fracture Surgery

Intertrochanteric FX for OBuzzWhile patients are sometimes concerned that resident involvement in their surgical case might lead to untoward outcomes, the article by Neuwirth et al. in the January 17, 2018 edition of JBJS provides data to alleviate some of those fears. The authors used the NSQIP database to evaluate whether resident involvement with the surgical treatment of intertrochanteric hip fractures resulted in increased 30-day mortality or morbidity, compared to similar cases in which a resident did not participate. The study found no differences in either 30-day mortality or severe morbidity between cases that involved a resident and those that did not.  However, cases involving residents did have significantly longer operative times, lengths of hospital stay, and times from operation to discharge.

These findings, which are similar to those of studies performed in other orthopaedic subspecialties, provide both relief and unease. Surgical education is built on apprenticeship and increasing autonomy throughout residency, so it is comforting that cases of this fracture type involving residents do not increase patient risks of mortality or severe morbidity. The findings suggest that residents are being appropriately supervised and given responsibilities that are commensurate with their level of training.

However, this study also shows that there is a price to be paid for resident education. Any “extra” time that a patient spends in the operating room or the hospital has associated costs to the health care system. Neuwirth et al. show that cases involving residents had a five times greater incidence of lasting more than 90 minutes and an average operative time that was more than 20 minutes longer, compared to cases not involving residents. If one were to extrapolate those added time-related costs across all intertrochanteric fracture surgeries performed in the US each year, the total added annual costs could be astronomical.

My concern is that as we move further toward value-based care, justifying these resident-training costs will become more challenging. Should resident involvement in a case be stopped after a certain amount of operative time? How close should a resident’s surgical time be to that of an attending surgeon’s by the time of graduation? What is the actual cost of resident training per surgical case? This study prompts these and similar difficult questions.

Education, like most investments, requires both time and money in order to pay dividends. While everyone can agree that it is important to train our future surgeons appropriately, there will likely be increasing pressure to do so in the most cost-efficient manner possible.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS 100: Knee Instability and Scoliosis

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Rotatory Instability of the Knee
Donald B. Slocum, Robert L. Larson: JBJS, 1968 Mar; 50 (2): 211
The authors demonstrated the importance of performing the anterior drawer test with the foot held in 15° of external rotation. The physical examination described in this article has since been complemented by numerous other tests.

Adolescent Idiopathic Scoliosis: A New Classification to Determine Extent of Spinal Arthrodesis
Lenke, Lawrence G. MD; Betz, Randal R. MD; Harms, Jürgen MD; Bridwell, Keith H. MD; Clements, David H. MD; Lowe, Thomas G. MD; Blanke, Kathy RN: JBJS, 2001 Aug;  83 (8): 1169
This new-at-the-time 2-dimensional classification system had three components: curve type, a lumbar spine modifier, and a sagittal thoracic modifier. It was much more reliable than previous systems in helping surgeons determine the vertebrae to be included in arthrodesis.

After TJA, Patients Living Alone Can Safely Be Discharged Home

elensreader.phpAs Fleischman et al. observe in the January 17, 2018 edition of The Journal, “there is a prevailing belief that patients living alone cannot be safely discharged directly home after total joint arthroplasty [TJA].” Not so, according to results of their Level II prospective cohort study.

The authors reviewed outcomes among a cohort of 769 patients undergoing lower-extremity arthroplasty who were discharged home, 138 of whom were living alone. While patients living alone more commonly stayed an additional night in the hospital and utilized more home-health services than patients living with others, there were no between-group differences in 90-day complication rates or unplanned clinical events, including readmissions.

These findings are reassuring, but all patients discharged home after a lower-limb arthroplasty need some support with meal preparation, personal hygiene, and other activities of daily living for the first 10 to 14 days. Clinicians should therefore adequately assess the local support system for each patient living alone in terms of family, neighbors, or friends to be sure the patient will be safe if discharged home. This crucial determination is a team exercise involving nursing, the surgeon, physical and occupational therapists, and a social worker. Fleischman et al. implicitly credit the “nurse navigator” program at their institution (Rothman Institute) with coordinating this team effort.

Investigation into these issues is very important as the orthopaedic community works to lower the costs of arthroplasty care while improving patient safety and satisfaction. If the appropriate support is in place, patients and clinicians alike would prefer that patients sleep in their own beds after discharge from joint replacement surgery.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

The Hippocratic Oath’s First Vow

WI Capture_1_12_18The January 3, 2018 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians.

This “What’s Important” article comes from Dr. Andrew J. Schoenfeld.

Dr. Schoenfeld reminds readers that the first vow of the Hippopcratic Oath is to “impart precept, oral instruction, and all other instructions” to help less-experienced physicians. In making a strong case for mentor-mentee relationships among today’s orthopaedists, Dr. Schoenfeld calls upon the “more seasoned clinicians among us to broadcast their ‘openness’ to serving as mentors.” He further promotes sponsorship, “the active process of engendering career opportunities for mentees.”

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.

JBJS 100: Pavlik Harness and the Infected TKA

jbjs_pl_journal_4c_5Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered activity on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are the first two:

  • Congenital Dislocation of the Hip
    PL Ramsey, S Lasser, GD MacEwen: JBJS, 1976 Oct; 58 (7): 1000
    The introduction of the Pavlik harness revolutionized the treatment of congenital dislocation of the hip in infants. The concept of the “safe zone” was introduced in this article.
  • Two-Stage Reimplantation for the Salvage of Infected Total Knee Arthroplasty
    J N Insall, F M Thompson, B D Brause: JBJS, 1983 Jan; 65 (8): 1087
    This was the first paper to show that a specific reimplantion protocol (debridement of the soft tissues and removal of the prosthesis and all cement, six weeks of parenteral antibiotics, and implantation of a new total knee) could provide predictable results in managing this difficult problem.