Archive | September 2019

What’s New in Hip Replacement 2019

Every month, JBJS publishes 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, Mengnai Li, MD, co-author of the September 18, 2019 “What’s New in Hip Replacement,” selected the five most clinically compelling findings from among the more than 100 studies summarized in the article.

THA Dislocation
–Pathology involving the spinopelvic relationship has dominated the recent literature on THA dislocation. For patients presenting with a flatback deformity and stiff spine, who had the highest risk of dislocation, the authors of a recent study suggested the use of a dual-mobility implant construct with targeted 30° of anteversion relative to the functional pelvic plane, based on a standing anteroposterior radiograph.1

Preferred Implant Designs
–A study comparing data from the American Joint Replacement Registry with national registry data from other countries found that cementless stem fixation with the use of ceramic and 36-mm heads was the current US preference, while non-US registries indicated that cemented implants and metal and 32-mm heads were used most commonly.2

Opioid Use
–The ongoing effort in the orthopaedic community to reduce opioid consumption without compromising quality of life for joint-replacement patients may be aided by findings from a recent randomized controlled trial. The study found that prescribing 30 immediate-release oxycodone pills instead of 90 pills was associated with a significant reduction in unused pills and decreased opioid consumption without affecting pain scores and patient-reported outcomes.3

Penicillin Allergy
– A retrospective review of >4,900 patients who underwent THA or TKA found that 16.2% reported a history of penicillin allergy. No patients among those with a stated penicillin allergy who were given cefazolin had an adverse reaction. Also, there was no increased rate of surgical site infections among those with a stated penicillin allergy who received clindamycin or vancomycin, although the authors acknowledged that this part of the study was underpowered due to the low overall rate of infection.4

Use of TXA
–Recent guidelines on the use of tranexamic acid (TXA) state that no specific routes of administration, dosage, dosing regimen, or time of administration have been shown to provide clearly superior blood-sparing properties.5

References

  1. Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem. J Arthroplasty.2019 Jan 18. [Epub ahead of print].
  2. Heckmann N, Ihn H, Stefl M, Etkin CD, Springer BD, Berry DJ, Lieberman JR. Early results from the American Joint Replacement Registry: a comparison with other national registries. J Arthroplasty.2019 Jan 5.
  3. Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, Gerlinger TL, Buvanendran A, Della Valle CJ. The James A. Rand Young Investigator’s Award: large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplasty.2019 Feb 4. [Epub ahead of print].
  4. Stone AH, Kelmer G, MacDonald JH, Clance MR, King PJ. The impact of patient-reported penicillin allergy on risk for surgical site infection in total joint arthroplasty. J Am Acad Orthop Surg.2019 Feb 27. [Epub ahead of print].
  5. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. Tranexamic acid use in total joint arthroplasty: the clinical practice guidelines endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty.2018 Oct;33(10):3065-9. Epub 2018 Aug 7.

Seeking Trauma Section Head for JBJS Clinical Classroom

JBJS is currently seeking a Trauma Section Head for the JBJS Clinical Classroom learning system. Clinical Classroom is an interactive, adaptive learning tool featuring more than 3,500 questions and comprehensive responses across 10 orthopaedic specialties. Questions and responses are clinically relevant, peer reviewed, and authored by orthopaedic surgeons. The platform also provides substantive Learning Resources that enhance the user experience.

The Section Head is responsible for leading a team of authors and developing new trauma-related content on a yearly basis. In addition, the Section Head will address user challenges and feedback. Ideally, candidates should be fellowship trained, in orthopaedic practice for at least 5 years, and have a passion for clinical education.

Click here for more information on the Clinical Classroom product.

If you are interested in this opportunity, please contact Chris Chiodo, Editor, JBJS Clinical Classroom at cchiodo@jbjs.org.  Please include your CV and a short statement describing your interest and experience in orthopaedic education.

Who’s at Risk for Prolonged Opioid Use after THA?

Much has been written in recent years about the orthopaedist’s predilection for prescribing opioids, most of which has been aimed at helping us become better stewards of these medications. It is imperative that we continue learning how best to prescribe opioids to maximize their effectiveness in postoperative pain management, while minimizing their many harmful and potentially lethal effects. With some patients, finding that balance is much easier than with others. Learning to identify which patients may struggle with achieving that equilibrium is one way to address the current opioid epidemic.

In the September 18, 2019 issue of The Journal, Prentice et al. identify preoperative risk factors that are associated with prolonged opioid utilization after total hip arthroplasty (THA) by retrospectively evaluating the number of opioid prescriptions dispensed to >12,500 THA patients. Many of the findings are in line with those of previous studies looking at this question. Prentice et al. found that the following factors were associated with greater opioid use during the first postoperative year:

  • Preoperative opioid use
  • Female sex
  • Black race
  • Anxiety
  • Higher BMI
  • Substance abuse
  • Back pain
  • AIDS
  • Chronic pulmonary disease

For me, the most noteworthy finding was that almost 25% of all patients in the study were still using opioids 271 to 360 days after their operation. That is a much higher percentage than I would have guessed prior to reading this study. Somewhat less surprising but also concerning was the finding that 63% of these patients filled at least 1 opioid prescription in the year prior to their THA, leading the authors to suggest that orthopaedic surgeons “refrain from prescribing opioids preoperatively” or “decrease current opioid users’ preoperative doses.”

Although some readers may be suffering from “opioid fatigue” in the orthopaedic literature, I encourage our community to  continue addressing our role in the current opioid crisis. While I believe that we have changed our prescribing practices since the data for this study were collected (2008 through 2011), we cannot dismiss these findings. The opioid epidemic is multifactorial and has many deep-rooted tendrils in our healthcare system. We owe it to our patients and to the public at large to be as significant a part of the solution as possible.

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

Elite Reviewer Spotlight: Keith Baumgarten

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Keith M. Baumgarten, MD.         

Affiliation: Orthopedic Institute, Sioux Falls, South Dakota

Years in practice: 14 years

How did you begin reviewing for other journals and for JBJS in particular?

When I began practice, I contacted the journal and volunteered to be a reviewer.  I believe that reviewing for journals is a service that we can provide to the orthopaedic community.  In addition, reviewing has helped me stay up to date in maintaining my orthopaedic knowledge base and has allowed me to become a better author as well.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

My advice is two-fold. First, it is important to understand that an author’s research and submitted manuscript can often be very dear to them.  They have invested countless hours in developing, performing, and writing their research.  This should be recognized so that we spend the appropriate time understanding their manuscript, determining its place in the orthopaedic literature, and providing an unbiased review.  Second, it is important to provide this review in a timely manner.  Authors often have to wait weeks or months to determine the status of their submission, and we as reviewers should try to minimize this.

Aside from orthopaedic manuscripts, what have you been reading lately?

The last three books I have read are Start With Why by Simon Sinek, Football for a Buck:  The Crazy Rise and Crazier Demise of the USFL by Jeff Pearlman, and On Desperate Ground: The Marines at The Reservoir, the Korean War’s Greatest Battle by Hampton Sides.

Learn more about the JBJS Elite Reviewers program.

Stop Adding Antibiotics to Irrigation Solutions

The rate of adoption of knowledge gleaned from multiple well-done randomized clinical trials into medical practice is disappointingly slow. This has been well-documented in cardiovascular medicine, and the examples in orthopaedic surgery are embarrassingly similar. A corollary phenomenon exists with the slow rate of transfer of information from basic science studies to orthopaedic clinical practice.

These “disconnects” occur largely because we tend to adopt the practices of our residency faculty, often without any rational inquiry. Having been an oral examiner for the Part II ABOS Oral Boards, I frequently asked, “Why did you decide on that approach to the patient’s problem?” And I often heard in response, “That’s the way it was done in my residency.”

In the September 18, 2019 issue of The Journal, Goswami et al,. report findings from a well-designed in vitro study demonstrating that the common practice of adding the antibiotics polymyxin and bacitracin to irrigation solution to lower the risk of infection is not based on sound evidence. While adding antibiotics might make intuitive sense, according to these authors, it is “a futile exercise.”

After testing 8 different irrigation solutions for efficacy against S. aureus and E. coli and for toxicity to musculoskeletal cells, Goswami et al. concluded that “our results provide further support for the use of dilute povidone-iodine because of its bactericidal properties, relatively limited toxicity,… and modest cost.” They go on to say that their findings bring into question the widespread usage of polymyxin-bacitracin.

Certainly, we need to assemble more evidence from additional research to identify the optimal irrigation solution for orthopaedic surgery, but in the interim, we should probably stop using polymyxin-bacitracin. Doing so would have the added benefits of lowering costs and not exacerbating the serious problem of antimicrobial resistance. There are many areas of clinical practice where we have no evidence either for against a particular approach. But when we do have solid evidence, even if it’s from an in vitro study, we should work together to improve the rates of adoption into clinical practice.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: Dominik Meyer

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Dominik C. Meyer, Prof. Dr. Med.

Affiliation: Balgrist Orthopaedic University Hospital, Zurich, Switzerland

Years in practice: 20 years

How did you begin reviewing for other journals and for JBJS in particular?

By introduction through my mentor, teacher, and chief Prof., Christian Gerber

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Try to put yourself into the position of both the reader and author at the same time, and handle the manuscript with the according care and respect.

Aside from orthopaedic manuscripts, what have you been reading lately?

Instruction manuals for my 3D printing software

Learn more about the JBJS Elite Reviewers program.

Elite Reviewer Spotlight: Samer Hasan

JBJS is pleased to highlight our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Samer Hasan, MD

Affiliation: Mercy Health – Cincinnati Sports Medicine and Orthopaedic Center

Years in practice: 19

How did you begin reviewing for other journals and for JBJS in particular?

My senior partners were doing it and so I got hooked. In the case of JBJS, I knew Dr. Andy Green and he knew me, and he began inviting me to review for the journal.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

Accept the invitations whenever possible, then read the manuscript carefully and try and understand the context and the methods. Don’t get too caught up in the minutiae.

Aside from orthopaedic manuscripts, what have you been reading lately?

Just finished reading Malcolm Gladwell’s Outliers. Very provocative.

Learn more about the JBJS Elite Reviewers program.

Chicago Orthopaedic Surgery PGY1 Journal Club Commentary

I was pleasantly surprised and excited when I first heard about the citywide Chicago PGY1 journal club. This journal club was funded by the Robert Bucholz Resident Journal Club Grant through The Journal of Bone and Joint Surgery. The premise of this program was for all of the orthopedic surgery PGY1s from around the city to meet and discuss landmark articles specific to a certain orthopedic topic. The event that I attended was the first meeting of the program, and the focus of our discussion revolved around four orthopedic trauma articles. I recognized all of the articles as the guidelines established from these papers are still used in our trauma practice every day.

Although I knew the general principles derived from this literature, I found reading the full text beneficial as it helped provide a more thorough background into the reasoning behind the decisions we make in the management of various fracture patterns. What I found most educational however was the discussions we had with residents at various programs, specifically in regards to our institutions’ management of common orthopedic fractures. We each went around the table and discussed our ED management of injuries including humeral shaft fractures, femoral shaft fractures, open fractures, and our intraoperative technique for intramedullary nailing of tibial shaft fractures.

While there were small differences in our management of these injuries, we all seemed to abide by the general guidelines that were set into motion after the publication of these landmark articles. It brought into focus how influential this literature has been, and also gave me additional insight into possible alternative management algorithms that could produce similar outcomes. When working at one institution throughout your residency, that institutions protocols often become the “normal” for you. I now better recognize that it is important to keep an open mind and that there can be many methods to achieve a desired result.

Our meeting allowed for a low stress environment to both appreciate and constructively criticize how we think about orthopedic trauma. At our specific institution the discussion of articles occurs in a large group setting with attendings and senior residents, and usually focuses on more recent literature. I think it is essential to understand where we came from, and this citywide journal club provides that history while also encouraging open critical discussion. I think any junior resident would benefit from this type of educational open forum with their colleagues.

You can apply for your own Robert Bucholz Resident Journal Club Grant by clicking this link.

Jeremy Adler

Orthopaedic Surgery, PGY-2

University of Chicago

Jeremy.adler@uchospitals.edu

Elite Reviewer Spotlight: Antonia Chen

In celebration of Peer Review Week, JBJS is pleased to present the first in a series of profiles highlighting our Elite Reviewers. The Elite Reviewers Program recognizes our best reviewers for their outstanding efforts. All JBJS reviewers help us maintain the highest standards for quality orthopaedic publishing.

Name: Antonia F. Chen, MD, MBA

Affiliation: Brigham and Women’s Hospital / Harvard Medical School, Boston, MA

Years in practice: 5

How did you begin reviewing for other journals and for JBJS in particular?

As a resident, one of my attendings asked me to review for a different journal given my interest in research.   The guidelines for reviewers were incredibly helpful, and I initially spent days reviewing a study trying to critically analyze it and provide constructive feedback. Subsequently, I met Dr. Tom Bauer at a meeting, and given my research interests, he invited me to review an article for JBJS. It’s been an incredible privilege to review for JBJS, and the critical thinking skills developed as a reviewer have helped me become a better writer.

What is your top piece of advice for those reviewers who aspire to reach Elite status?

The more you practice reviewing, the more intuitive it becomes; try to do as many reviews as possible. I like to read an article twice – once to get the general gestalt of an article to understand if/how everything ties together, then a second time to critically analyze the article and try to find loopholes in the article. By doing so, I am able to understand the big picture before getting into the details of a manuscript.

Aside from orthopaedic manuscripts, what have you been reading lately?

I recently read The Life Changing Magic of Tidying Up. I have so many changes to make!

Learn more about the JBJS Elite Reviewers program.

Mehta Casting for Early-Onset Scoliosis: Predictors of Success

The treatment of early-onset scoliosis with Mehta casting is a long process, but if successful, it can delay or obviate the need for surgery. In the September 4, 2019 issue of JBJS, Fedorak et al. examine outcomes among 38 patients (mean age of 24 ± 15 months at time of first casting) who were treated with Mehta casting and followed for a mean of 8 ± 2 years. The retrospective review identified differences between patients who had a Cobb angle ≤15° (improvement group) at the most recent follow-up and those who had a Cobb angle of >15° (no-improvement group).

Forty-nine percent of children had achieved and maintained scoliosis of ≤15° at the time of the most recent follow-up, and 73% were improved by at least 20°, although 3 children ended up relapsing after meeting recommended criteria for discontinuation of casting. There was no significant difference in thoracic-height gain between the groups, demonstrating that even when scoliosis was not corrected, growth was maintained during cast treatment.

Patients in the improvement group had a mean age of 18.9 ± 12 months and scoliosis of 48.2° ± 14° at the initiation of treatment. Here are 3 additional factors that were associated with a greater likelihood of scoliosis of ≤15°:

  • A lower pre-treatment Cobb angle and traction Cobb angle
  • A smaller rib-vertebral angle difference on first-in-cast radiograph
  • A lower Cobb angle on first-in-cast radiograph

The authors note that although this study analyzed longer-term follow-up data than most other similar investigations, “treatment of early-onset scoliosis is not truly finished until skeletal maturity has been reached.”