Archive | October 2019

Elite Reviewer Spotlight: Stein Janssen

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: Stein J. Janssen, MD, PhD

Affiliation: Academic Medical Center, Amsterdam, The Netherlands

Years in practice: I’m a 4th year resident in orthopaedic surgery.

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

I first reviewed some papers together with more experienced researchers and staff. Subsequently, I approached the Editor-in-Chief of two other top orthopaedic journals during a meeting and started reviewing. I reached out to JBJS after reading an editorial from Dr. Swiontkowski about the value of peer review and started reviewing soon thereafter.

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

Present a well-structured and detailed review suggesting ways for researchers to improve their work instead of only criticizing the manuscript. Several reporting guidelines (e.g. STROBE, PRISMA, CONSORT) can help to systematically evaluate a manuscript. In addition, review in a timely fashion.

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

I always check the table of contents of the top 4 medical journals (NEJM, the Lancet, BMJ, and JAMA) and read the most interesting papers.

Learn more about the JBJS Elite Reviewers program.

Eschew the “Quick Fix” Approach to Early Knee OA

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in Arthritis Care & Researchthe following commentary comes from Jeffrey B. Stambough, MD.

As orthopaedic surgeons, we share a collective objective to help patients improve function while minimizing pain. When patients come to our office for a new clinical visit for knee osteoarthritis (OA), we spend time getting to know them and gathering information about their activities, limitations, and functional goals. We balance this patient-reported information with discrete data points, such as weight, range-of-motion restrictions, and radiographic disease classification. Based on the symptom duration and other factors, most patients are not candidates for a knee replacement at this first visit. However, despite the publication of clinical practice guidelines for the nonoperative management of knee OA in 2008, with an update in 2013, significant variation exists in how orthopaedists treat these patients.

This guideline–practice disconnect is emphasized in findings from a recent study in Arthritis Care & Research that examined nonoperative knee OA management practices during clinic visits between 2007 and 2015. The authors found that the overall prescription of NSAID and opioid medications increased 2- and 3-fold, respectively, over that time, while recommendations for lifestyle interventions, self-directed activity, and physical therapy decreased by about 50%.

To me, the most troubling finding from this study is the sharp increase in narcotic prescriptions, because recent evidence demonstrates that narcotics do not effectively treat arthritis pain. Moreover, for patients who go on to arthroplasty, recent studies have found that preoperative opioid use portends worse postsurgical outcomes in terms of higher revision rates,  worse function scores, and decreased knee motion.

The findings from this study also speak to a larger societal issue for doctors and patients alike: the desire for a “quick fix.”  Despite the time pressure from increasing EHR documentation burdens, dwindling reimbursements, or lack of local resources, we owe it to our patients to counsel them on lifestyle modifications and self-management strategies to help them stay mobile, lose weight (if necessary), and take charge of their joint health. As orthopaedic surgeons, we must continue to strive to de-emphasize opioid pain medication when treating knee OA patients and support them in a holistic manner to ensure their overall health and the function and longevity of their native knee joint.

Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.

Elite Reviewer Spotlight: Mary Forte

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: Mary L. Forte, PhD, DC

Affiliation: University of Minnesota, School of Public Health (primary), and Northwestern Health Sciences University

Years in practice: I practiced chiropractic for 19 years, and nursing (RN) prior to that. I’ve been working as a PhD in health services research since 2009.

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

I was electronically invited to review an article for JBJS that was in my area of expertise. I had reviewed for several other journals prior to that, one of which was an orthopedic journal.

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

Keep your reviewer profile for Unavailable Dates current, especially when unforeseen life events come up. My reviews have been delayed when I have forgotten to change my availability promptly.

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

Varies and is free-time dependent.

Learn more about the JBJS Elite Reviewers program.

Subtalar Joint’s Middle Facet Yields Insight into Flatfoot

Many foot and ankle surgeons would relish a simple measurement made from a readily available imaging modality to help detect whether patients with adult acquired flatfoot deformity (AAFD) are at high risk for progressive collapse—and to help them with surgical planning. According to the findings from a case-control study by de Cesar Netto et al. in the October 16, 2019 issue of The Journal of Bone & Joint Surgery, that wish may soon be realized.

The authors made standing, weight-bearing computed tomography (CT) scans of 30 patients with stage-II AAFD (mean age of 57.4 years) and 30 matched controls (mean age of 51.8 years). From those images, 2 fellowship-trained surgeons, who were blinded regarding the patient cohorts, measured the amount of subluxation (percentage of uncoverage) and the incongruence angle of the middle facet of the subtalar joint in the coronal plane. The authors found substantial to almost perfect intraobserver and interobserver reliability for both measurements.

Based on these middle-facet measurements, the mean value for joint uncoverage in patients with AAFD was 45.3% compared with 4.8% in controls. Similarly, the mean incongruence angle in the AAFD group was 17.3° in the AAFD group and 0.3° in controls. Further analysis led the authors to conclude that “an incongruence angle of >8.4° and an uncoverage percentage of 17.9% were found to be highly diagnostic for symptomatic stage-II AAFD.”

De Cesar Netto et al. say the biomechanics of the subtalar joint made focusing on the middle facet a sensible approach, and they attributed the high reliability of the measurements to the relatively simple anatomy of the middle facet. Still, because clinical outcomes were not assessed in this study, the role of the middle facet as a marker of peritalar subluxation and a tool for deformity correction in AAFD patients needs further investigation in prospective, longitudinal studies.

Elite Reviewer Spotlight: Peter Murray

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: Peter M. Murray, MD

Affiliation: Mayo Clinic, Jacksonville, FL

Years in practice: 27 years

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

Personal invitations

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

Concentrate on the methodology of the manuscript you are reviewing – most manuscript problems can be traced back to faulty methodology.

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

The Biography of Ulysses S. Grant.

Learn more about the JBJS Elite Reviewers program.

Orthopaedic Interns Across Chicago Learn and Bond in Journal Club

OrthoBuzz occasionally receives posts from guest bloggers. The following contribution comes from Rob Christian, MD and Maddy Lyons, MD.

Editor’s Note: The application deadline for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program has been extended to November 1, 2019.

Junior residents often hear attendings, fellows, and senior residents quote landmark studies, but few find the time to track down and read these important papers on their own. So, when the Northwestern University Orthopaedic Residency Program was awarded one of the JBJS Robert Bucholz Resident Journal Club Grants, Haley Smith, MD (PGY-2) and I used the funding to pilot an Intern Journal Club, inviting all the interns in orthopaedic surgery residency programs across Chicago to read and discuss landmark studies.

Over the last decade, several hospitals in Chicago, such as John H. Stroger, Jr. Hospital of Cook County and Ann & Robert H. Lurie Children’s Hospital of Chicago, have trained teams of orthopaedic residents from multiple programs. Working in the hospital with residents from different programs is a great educational experience, and we thought these resident teams could be even more effective if they interacted with one another prior to working together in the hospital.

Our Intern Journal Club met quarterly, and had impressive attendance, especially considering the busy intern work schedule. Each journal club session featured 4 to 5 landmark studies (suitable for PGY-1s), and discussions were led by senior residents selected across the programs.  Articles discussed came from all orthopaedic subspecialties. In addition to literature-based discussions, the get-togethers fostered collegial relationships among the different programs.

For me, the most rewarding part of the Intern Journal Club has been meeting the interns as they begin their residencies and guiding discussion to help them think critically about orthopaedic literature. With the continued support of the JBJS Robert Bucholz Resident Journal Club Grant, we look forward to continuing to host the Intern Journal Club for this year’s intern class.

Rob Christian, MD (PGY-5)
McGaw Medical Center of Northwestern University

*          *          *          *

Initially, the JBJS Chicago Intern Journal Club felt like it was adding articles to an endless intern reading list. However, it turned out to be one of the more valuable and fun educational experiences of my intern year.

The meetings provided the unique opportunity to meet residents from the other Chicago programs. Exchanging stories of intern-year trials and tribulations quickly bonded our group. It was interesting to discover the differences and similarities in our programs, our rotations, and even in the ways in which we manage injuries. In addition to building relationships with peers across programs, the journal clubs allowed me to connect with senior residents who have similar career interests and build several new mentorships.

The articles that we read and discussed were landmark studies that shape the practice of orthopaedics on a daily basis. Through morning conferences, OITE practice questions, and clinical care, interns are exposed repeatedly to fundamentals of orthopaedics, such as open fracture management and functional bracing of humeral shaft fractures. However, without our Intern Journal Club, I may not have explored the studies on which these practice-shaping principles are built. An open, discussion-based format with senior residents helped me understand the “whys” of what we are taught.

We are fortunate to have so many great orthopaedic residency programs in Chicago, each with unique strengths. I hope that our Intern Journal Club continues in the years to come to inspire future collaboration in educational, social, and networking events among the local residency programs.

Maddy Lyons, MD (PGY-2)
Loyola University Medical Center

What’s New in Shoulder and Elbow Surgery 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 such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.

–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4

–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5

Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:

  • Smaller overall lesion size
  • No clear margins of the fragment on MRI
  • Absence of cyst-like lesions

The authors include a nomogram that clinicians can use to predict healing.

UCL Insufficiency
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:

  • Position players returned to play sooner than pitchers, but they had lower rates of return to play.
  • Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).

These findings could help clinicians set expectations for players undergoing UCL reconstruction.

References

  1. Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
  2. Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
  3. Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
  4. Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
  5. Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
  6. Niu EL, Tepolt FABae DSLebrun DGKocher MSNonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment successJ Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
  7. Camp CL, Conte SD’Angelo JFealy SAFollowing ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequentlyJ Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.

Elite Reviewer Spotlight: Sophia Sangiorgio

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: Sophia N. Sangiorgio, PhD

Affiliation: Orthopaedic Institute for Children / UCLA Departments of Orthopaedic Surgery and Bioengineering, Los Angeles, CA

Years in practice: I am a biomechanical engineer, specializing in orthopaedic implant performance. I have been working in orthopaedic research for nearly 20 years and on the UCLA faculty for 12 years.

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

I have been reviewing manuscripts for JBJS for 5 years, and reviewing for other orthopaedic journals, both clinical and biomechanical, for 10 years.

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

Take time to provide constructive feedback that provides the authors with a chance to respond and the means to improve their manuscript.

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

Current concepts in preventative health, with a focus on increasing health span (prolonging physical and mental performance) and not simply lifespan. I also enjoy reading fiction to relax and unwind.

Learn more about the JBJS Elite Reviewers program.

MRI for Detecting Rapidly Progressive Knee OA: No Crystal Ball

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.

Knee osteoarthritis (KOA) typically develops over a decade or more. However, 1 in 5 people with KOA have more pain and disability at onset, have accelerated radiographic knee osteoarthritis (AKOA), and experience end-stage disease within 4 years. The use of demographics and clinical findings has resulted in only a 40% rate of correctly classifying patients who will develop AKOA instead of longer-term KOA.

Investigators recently conducted a case–control study using data from the OsteoArthritis Initiative (OAI), including demographic, clinical, and biochemical data, along with radiographic and magnetic resonance (MR) imaging data.1 The researchers hypothesized that the addition of an MR imaging-based scoring system would more accurately identify patients at risk for AKOA. They used classification and regression tree (CART) models to assess the ability of baseline MR features to classify participants who will develop AKOA and whether adding baseline MR features to an existing model improved classification of adults who will develop AKOA.

The existing model consisted of clinical data that included pain, function, physical exam findings, and quality-of-life measures. Demographic data included age, sex, and BMI collected at baseline. Biochemical data included high-sensitivity C-reactive protein and serum blood sugar. Data obtained from MR imaging scores included bone marrow lesion volume, effusion-synovitis volume, cartilage damage index, meniscal extrusion and degeneration, cruciate ligament degeneration, and patellar fat pad changes.

Contrary to the hypothesis, the CART models with and without MR features each explained approximately 40% of the variability. Adding MR-based features to the model improved specificity (0.90 vs. 0.82), but lowered sensitivity (0.62 vs. 0.70). Interestingly, the authors found that serum glucose, effusion-synovitis volume, and cruciate ligament degeneration were statistically important variables in classifying individuals who are likely to develop AKOA.

The clinical take home is that early MR data may be useful in sorting out mechanical complaints, but not in determining who will develop AKOA. In contrast, in later stages of KOA, MR images may reveal far greater damage than can be detected on radiographs.

Reference

  1. Price LL, Harkey MS, Ward RJ, MacKay JW, Zhang M, Pang J, Davis JE, McAlindon TE, Lo GH, Amin M, Eaton CB, Lu B, Duryea J, Barbe MF, Driban JB. Role of Magnetic Resonance Imaging in Classifying Individuals Who Will Develop Accelerated Radiographic Knee Osteoarthritis. J Orthop Res. 2019 Nov;37(11):2420-2428. doi: 10.1002/jor.24413. Epub 2019 Jul 29. PMID: 31297900

“Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost

Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.

In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.

Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does  suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.

As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study.  A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media