The evidence favoring tranexamic acid (TXA) for reducing surgical blood loss is ample and growing, but until now robust data were sparse regarding its efficacy in the setting of adolescent idiopathic scoliosis surgery. In the December 5, 2018 issue of The Journal of Bone & Joint Surgery, Goobie et al. report on a randomized, blinded, placebo-controlled trial showing that, in that population, TXA reduced perioperative blood loss by 27%, compared with blood loss in a placebo group.
Even with recent advances in scoliosis surgical technique, blood transfusions are common. And, because transfusions are associated with significant morbidity and mortality, limiting operative blood loss and reducing the need for transfusion have become focal points for orthopaedic surgeons.
In this Level-I trial, >100 patients between the ages of 10 and 18 years undergoing elective posterior instrumented spinal fusion were randomized to receive either TXA (infusion of a 50-mg/kg loading dose and a 10-mg/kg/h maintenance dose) or normal saline (delivered in the same way and dose) during surgery. The TXA group demonstrated an overall 27% reduction in cumulative blood loss and a 2-fold reduction in the percentage of patients with clinically relevant blood loss (defined as >20 mL/kg).
The cumulative effect of reduced blood loss was enhanced over time, with the positive effect of TXA being most evident in procedures lasting >4 hours. None of the patients in the TXA group required a transfusion or developed side effects such as thromboembolism or seizures.
In an interesting sidenote, the authors asked the participating orthopaedic surgeons, who were blinded to the randomization, to guess which group each patient had been assigned to by evaluating the relative ooziness of the surgical field. The surgeons guessed correctly 72% of the time.
Overall, these findings prompted the authors to conclude that “the use of TXA as part of a multimodal blood management strategy, as was employed in this study, should be considered the standard of care for patients undergoing surgery for adolescent idiopathic scoliosis.”
Osteoporosis is a “silent” disease, often becoming apparent only after a patient older than 50 sustains a low-energy fracture of the wrist, proximal humerus, or hip. Monitoring serum vitamin D levels and DEXA testing represent ideal screening methods to prevent these sentinel fragility fractures. In addition, through programs such as the AOA’s “Own the Bone” initiative, the orthopaedic community has taken a leadership role in diagnosing and treating osteoporosis after the disease presents as a fragility fracture. Own the Bone is active in all 50 states and, through local physician leadership, is identifying individuals who present with a fragility fracture so they can receive follow-up care that helps mitigate bone loss and prevent secondary fractures.
We still have a long way to go, however. Recent analyses show that only 30% of candidate patients (albeit up from 20%) are receiving this type of evidence-based care. The best-case scenario would be to identify at-risk men and women (osteoporosis does not affect women exclusively) before a potentially serious injury.
In the December 5, 2018 issue of The Journal, Anderson et al. present strong evidence that computed tomography (CT) can provide accurate data for diagnosing osteoporosis. CT is increasingly used (perhaps overused in some settings) across a spectrum of diagnostic investigations. The osseous-related data from these scans can be used to glean accurate information regarding a patient’s bone quality by analyzing the Hounsfield unit (HU) values of bone captured opportunistically by CT. HU data are routinely ignored, but the values correlate strongly with bone mineral density, and they could help us recommend preventive care to our patients before a fragility fracture occurs. (For example, a threshold of <135 HU for the L1 vertebral body indicates a risk for osteoporosis.)
Orthopaedists should discuss the possibility of asking their radiologist colleagues who read CT scans of older patients to routinely share that data. When indicated, we could promptly refer patients back to their primary care provider for discussion of pharmacological treatment and lifestyle changes proven to help prevent primary fragility fractures. There is little doubt that our patients are getting older. Reviewing CT data could help us dramatically improve preventive care and decrease the risk of first-time fragility fractures.
Click here for additional OrthoBuzz posts about fragility fractures.
Marc Swiontkowski, MD
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, Matthew J. Allen, VetMB, PhD, author of the December 5, 2018 Specialty Update on Musculoskeletal Basic Science, focuses on the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.
Gene Editing in Orthopaedics
–Gene-editing tools such as CRISPR-Cas9 have great potential as a means of introducing therapeutic genes into mesenchymal stem cells that can then be targeted to tissues in vivo. These researchers1 reported on genetically modified stem cells that have the potential to differentiate into chondrocytes encoding a natural inhibitor of interleukin-1, providing an opportunity for localized release of immunomodulatory factors.
Managing Orthopaedic Infections
–A novel study2 in which transmission electron microscopy was used to identify viable bacteria deep within the canalicular structure of cortical bone, remote from the site of an infected implant, suggests that effective debridement requires the removal of not just necrotic tissue, but also of adjacent, apparently unaffected bone.
Computational Modeling of Human Movement
–This report3 presented a human musculoskeletal model that provided extremely accurate predictions of ground reaction forces during simulated walking and squatting. As similar models are developed and validated, surgeons will have improved tools for evaluating patients, planning surgery, and making decisions about which procedure/implant is most appropriate for an individual patient.
–This report4 demonstrated sexually dimorphic regulation of gene-expression profiles in bone marrow osteoprogenitor cells that could partly explain clinical observations in sex differences in peak bone mass, bone remodeling, and immunomodulation.
Biological Enhancement of Ligament Healing
–Among several basic science papers focused on the optimal healing and durable fixation of tendons and ligaments, this notable work5 reported on the translation of bridge-enhanced ligament repair for the anterior cruciate ligament.
- Brunger JM, Zutshi A, Willard VP, Gersbach CA, Guilak F. CRISPR/Cas9 editing of murine induced pluripotent stem cells for engineering inflammation-resistant tissues. Arthritis Rheumatol.2017 May;69(5):1111-21. Epub 2017 Mar 31.
- de Mesy Bentley KL, Trombetta R, Nishitani K, Bello-Irizarry SN, Ninomiya M, Zhang L, Chung HL, McGrath JL, Daiss JL, Awad HA, Kates SL, Schwarz EM. Evidence of Staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis. J Bone Miner Res.2017 May;32(5):985-90. Epub 2017 Jan 26.
- Jung Y, Koo YJ, Koo S. Simultaneous estimation of ground reaction force and knee contact force during walking and squatting. Int J Precis Eng Manuf.2017;18(9):1263-8.
- Kot A, Zhong ZA, Zhang H, Lay YE, Lane NE, Yao W. Sex dimorphic regulation of osteoprogenitor progesterone in bone stromal cells. J Mol Endocrinol.2017 Nov;59(4):351-63. Epub 2017 Sep 4.
- Perrone GS, Proffen BL, Kiapour AM, Sieker JT, Fleming BC, Murray MM. Bench-to-bedside: bridge-enhanced anterior cruciate ligament repair. J Orthop Res.2017 Dec;35(12):2606-12. Epub 2017 Jul 9.
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:
Tibia Vara: Osteochondrosis Deformans Tibia
WP Blount: JBJS, 1937 January; 19 (1): 1
In this classic article, Blount detailed clinical and radiologic features of the affected lower extremities of 13 children with bowlegs. Nearly 80 years have passed since Blount’s original description, and not much more is known about this enigmatic developmental disorder. Given the potential for less postoperative morbidity, there has been a resurgence of “guided growth” strategies to treat this and other pediatric limb deformities.
Lumbar Disc Disorders and Low-back Pain: Socioeconomic Factors and Consequences
JN Katz: JBJS, 2006 April; 88 (Suppl 2): 21
The 21st century has brought with it a sharper focus on both the socioeconomic factors contributing to medical conditions and the socioeconomic consequences of those conditions. Back in 2006, Dr. Katz found that the total annual costs of low back pain in the US exceeded $100 billion, two-thirds of that in the form of indirect costs (e.g., lost wages and reduced productivity). He also found that fewer than 5% of patients who have a low back pain episode account for 75% of the total costs, prompting Dr. Katz to emphasize the ongoing “critical importance of identifying strategies to prevent these disorders and their consequences.”
It’s been more than a year since OrthoBuzz revisited the topic of predatory publishing (see related OrthoBuzz articles), but the comprehensive “Orthopaedic Forum” about this unsavory subject in the November 7, 2018 issue of JBJS warrants our attention.
In a meticulous investigation focused just on orthopaedic literature, Yan et al. found 104 suspected predatory publishers, representing 225 possible predatory journals. That’s nearly 3 times as many bogus publications as the 82 legitimate orthopaedic journals that the authors also identified. Somewhat disturbingly, 20 of the presumably predatory journals were also found to be indexed in PubMed.
The median article processing charge (APC) among predatory journals was $420, compared with $2,900 for legitimate journals. (Lower APCs tend to lure more researchers—especially younger ones—into the scams.) The most prevalent countries of origin of the predatory journals were India, the US, and the UK, while most of the authors publishing in predatory journals were from India, the US, the UK, and Japan. Predatory publishers are clearly taking advantage of the widespread pressure on researchers to publish as an avenue for career advancement.
The authors reiterate previously cited “red flags” that can tip off researchers to possibly predatory journals:
- Very low article processing fees
- Spelling and grammatical errors on the journal’s website
- Overly broad scope
- Language that targets authors more than readers
- Promises of rapid publication
- Dearth of information about copyright, retraction policies, or digital preservation
Yan et al. conclude that “ the scientific community needs to increase awareness of how to identify and avoid predatory journals. This is especially important for junior researchers…”
If you want more information about specific predatory journals, see Table II of the article (“List of Suspected Predatory Journals in the Field of Orthopaedics”), which includes the criteria that prompted the authors to categorize them as predatory.
Jason Miller, JBJS Executive Publisher
Lloyd Resnick, JBJS Developmental Editor
Concerns have arisen that the implementation of value-based, alternative payment models pegged to “bundled” episodes of care and/or patient outcomes may make it harder for a subset of patients to access the care they need. Specifically, some surgeons may be apprehensive to treat patients who have substantial medical comorbidities or socioeconomic situations that increase their risk of postsurgical complications and poor outcomes, because these alternative payment models often financially penalize physicians and hospitals for the cost of suboptimal results. The study by Shau et al. in the December 5, 2018 issue of The Journal provides data that sharpens the horns of this dilemma.
The authors used the National Readmissions Database to perform a propensity-score-matched comparison between >5,300 patients with Medicaid payer status who underwent a primary total hip arthroplasty (THA) and an equal number of patients with other types of insurance who also underwent primary THA. Shau et al. found that Medicaid-covered THA patients had significantly increased overall readmission rates (28.8% vs 21%, p <0.001, relative risk=1.37), mean length of stay (4.5 vs 3.3 days, p <0.0001), and mean total cost of care ($71,110 vs $65,309, p <0.0001), relative to the other group. These results strongly suggest that Medicaid payer status is an independent factor associated with increased resource utilization after total hip arthroplasty.
These findings can be viewed from a couple of different perspectives. First, from a preventive standpoint, surgeons and healthcare systems providing THA for Medicaid patients may need to spend more time preoperatively optimizing these patients (both physically and psychosocially) to decrease their postoperative resource burden and increase the likelihood of a good clinical outcome. Second, these results are further proof that any fair and effective alternative payment model needs to take into consideration factors such as Medicaid payer status and patient comorbidities. If they do not, such models will actually throw access barriers in front of patients in this demographic because providers may feel that caring for them increases the likelihood of being penalized financially.
Both perspectives are valid, so Medicaid payer status is a crucial factor to consider as alternative payment programs move forward. Nowadays, controlling costs is an important goal of any healthcare delivery system, but it must not lead to unintended discrimination in patient access to care. As we create further alternative payment models and refine existing ones, we must be careful not to prioritize cost cutting ahead of equitable patient access.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media