OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Carl Nunziato, MD and Anthony Johnson, MD in response to a TV news segment on WLWT in Cincinnati.
While viewing the WLWT segment on youth sports injury, we were encouraged that the reporter sought out a local orthopedic surgeon to comment on the risks associated with single-sport specialization. As orthopaedic surgeons, our opinions are a trusted voice in our communities, and we need to educate athletes, coaches, and parents alike of the dangers of such specialization. We commend Dr. Timothy Kremchek for his involvement in his local community and have felt the frustration he expressed regarding the rising sport-injury rates among adolescents.
However, we caution providers against characterizing single-sport specialization as “child abuse,” as Dr. Kremchek did in this segment. This extreme language, even if used to emphasize the potentially serious nature of some sport injuries, is counterproductive. Instead, we encourage all musculoskeletal clinicians to focus on educating the public on how to reduce risk in adolescent athletes, rather than shaming or blaming.
We’ve helped many patients—both minors and adults—as they struggled to rehab from injuries, only to realize that returning to the same level of competition may not be possible. In such cases, many patients and/or their parents ask the same guilt-ridden questions as the mother of the young basketball player in the news segment: “Did I make a mistake? Did I push too hard?”
It is true that youthful participation in a single sport year-round has been shown to result in increased injury rates, burnout, and possibly even limitations in peak performance in the chosen sport due to delayed development of other muscle groups and fine motor skills. We also cannot deny the risks and costs associated with the increase in operations on young athletes. It’s key to remember, however, the principal concept of patient autonomy. As the young patient in the story reminds us, these kids often truly love their sport – and many would choose to continue participating even if they knew the risk and seriousness of eventual injury.
Instead of using sensational phrases like “child abuse,” which may frighten families or stir up feelings of guilt, we should provide resources for coaches, parents, physicians, and athletes aimed at encouraging healthy participation and minimization of one-sport injuries. One example is the AAOS/AOSSM OneSport initiative. Educating patients and their families requires significant time and effort on the part of the orthopaedic surgeon, but it is likely to result in a more positive interaction with the patient and parents. And these interactions may help emphasize the long-term lifestyle behaviors that we are hoping to cultivate among these vulnerable populations.
Carl A. Nunziato, MD is a resident in orthopaedic surgery at Dell Medical School in Austin, Texas. Anthony Johnson, MD is the orthopaedic surgery residency program director in the Department of Surgery and Perioperative Care at Dell Medical School.
Under 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 was 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 full-text 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:
Closed Intramedullary Nailing of Femoral Fractures
RA Winquist, ST Hansen Jr, DK Clawson: JBJS, 1984 January; 66 (4): 529
This paper, which carefully explains how IM nailing procedures were refined as the authors’ experience grew from 1968 to 1979, ushered in the standard of care that exists today and spelled the end of traction treatment and plate fixation. It remains one of the most-cited articles in the history of musculoskeletal trauma literature.
Nonoperative Treatment of Primary Anterior Shoulder Dislocation in Patients 40 Years of Age and Younger
L Hovelius et al: JBJS, 2008 May; 90 (5): 945
After 25 years of follow-up, half of >200 primary shoulder dislocations in Swedish patients aged 12 to 25 that had been treated nonoperatively had not recurred or had become stable over time. Based on these findings, the authors opine that “routine, immediate surgery for the treatment of all first-time dislocations in patients 25 years of age or younger will result in a rate of unnecessary operations of at least 30%.”
Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma
Perioperative Tranexamic Acid Treatment and Risk of Cardiovascular Events or Death After Total Hip Arthroplasty
Prior research has established that total hip arthroplasty (THA), in and of itself, is associated with a small increased risk of venous thromboembolism (VTE). Hence the concern that routinely administering the antifibrinolytic drug tranexamic acid (TXA) perioperatively, as is commonly done nowadays to reduce blood loss during surgery, might further increase the risk of THA-related thromboembolic events. But the findings from a large population-based cohort study by Dastrup et al. in the October 17, 2018 JBJS, should allay many of those concerns.
The authors evaluated >45,000 Danish patients who had a THA between 2006 and 2013. Approximately 85% of those patients received intravenous TXA perioperatively, while the rest did not. Dastrup et al. evaluated adverse cardiovascular events (VTE, deep venous thrombosis, pulmonary embolism, myocardial infarction, and ischemic stroke) among those patients over 30 postoperative days, and they found no increased risk in any of those outcomes among the patients who received TXA relative to those who did not. These optimistic findings were essentially the same when the authors analyzed the data using a multivariable model and with propensity-score matching.
Dastrup et al. conclude that TXA in the setting of THA is safe with respect to VTE, and David Ayers, MD, commenting on the study, concurs. However, Dr. Ayers cautions that the study did not have the statistical strength to evaluate the potential cardiovascular risks of TXA in THA patients who have undergone previous cardiac procedures, such as stent placement. He therefore suggests that “further safety evaluation should be directed toward [such] patients at higher risk for complications after receiving TXA.”
On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:
- Regis O’Keefe, MD, PhD, FAOA
- Mary O’Connor, MD, FAOA
- Julie Samora, MD, PhD, MPH
- Kristy Weber, MD, FAOA
- Lisa Lattanza, MD, FAOA
Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.
Seats are limited, so REGISTER NOW.
This post 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.
A bioﬁlm is a complex combination of extracellular carbohydrates, proteins, lipids, and one or more species of bacteria that may adhere to an orthopaedic implant and surrounding tissue (see related OrthoBuzz post). Staphylococci bacteria are believed to account for more than 50% of all bioﬁlm infections of medical devices.
Researchers recently summarized what we know about the biofilm formation process.1 In the attachment phase, free-floating bacteria attach to a prosthetic surface via proteins. Extracellular DNA from autolysis add to the mix. Then begins the irreversible attachment phase, during which the initial bacteria are incarcerated while more free-floating bacteria are added. During this phase, autoinducers are expressed, which serve as inter- and intrabacterial signals.
In the presence of an adequate quorum of bacteria, the maturation phase begins, during which the bacterial population cohesively shifts from replication to expression of virulence factors such as secretion systems, toxins, or bioﬁlm formation. A mature biofilm is immune-resistant, although bacterial replication decreases. In the dispersal phase bacteria become planktonic again, potentially available to repeat the process.
Once a biofilm has formed, antibiotic administration becomes problematic because of the toxicity of the high doses needed to treat biofilm colonies. An underlying challenge with pharmacologic intervention is the variety of quorum-sensing communication pathways between bacterial species. The authors suggest that a future biofilm-fighting strategy may be to force bacteria into bioﬁlm-forming behavior before they reach the necessary critical density to become virulent, although this notion remains unexplored. Researchers are investigating other possible strategies to disrupt the quorum-sensing communication among bacteria that enable them to behave as a “social” group.
- Mooney JA, Pridgen EM, Manasherob R, Suh G, Blackwell HE, Barron AE, Bollyky PL, Goodman SB, Amanatullah DF. Periprosthetic bacterial biofilm and quorum sensing. J Orthop Res. 2018 Sep;36(9):2331-2339. doi: 10.1002/jor.24019. Epub 2018 May 24.
Until I completed my pediatric orthopaedics rotation as a resident, I never thought much about pediatric lawn-mower injuries. I don’t recall how many such accidents we cared for during that time period, but I clearly remember one. It was grotesque and life-changing for the child–and definitely avoidable. That recollection was reinforced while I read the epidemiological study by Fletcher et al. in the October 17, 2018 edition of The Journal.
The authors analyzed 20 years of data from their institution in an effort to better understand these horrific injuries. They found two main demographic populations among the 157 patients who sustained mower-related injuries, which were lower-extremity injuries in 84% of all the patients. Those in the younger at-risk population (mean age of 4 years) were frequently injured by (or were passengers on) a riding lawn mower, usually operated by an older family member. This younger cohort had higher injury severity scores and higher amputation rates than the older pediatric population of mower-injured patients (mean age of 15 years). Most of those older patients were hurt while operating the lawn mower themselves. Not surprisingly, the authors found that these patients, whatever their age, underwent an average of almost three operations and spent close to a week in the hospital.
While there are a lot of important epidemiological data points in this article, the most important take-home message is the role that education must play in the prevention of these injuries. As the author state:
Education for the younger population should target the operators (parents, grandparents, older siblings) and emphasize the importance of keeping children out of the yard while lawn mowers are in use. Under no circumstance should a child of any age be the passenger on a lawn mower.
Despite ample literature on lawn-mower injuries, their incidence among pediatric patients has remained largely unchanged. I’m hopeful that this study will prompt more widespread implementation of patient education in this area. The American Academy of Orthopaedic Surgeons has information regarding lawn mower safety, and the Pediatric Orthopaedic Society of North America and the American Academy of Pediatrics are partnering on lawn-mower injury prevention. Accidents cannot be eradicated completely, but the more we avail ourselves of resources such as these—and share them with patients of all ages—the greater the likelihood of preventing these potentially devastating injuries.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media