Archive | February 2020

Elite Reviewer Spotlight: Terence McIff

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: Terence E. McIff, MBA, PhD

Affiliation:

University of Kansas Medical Center, Kansas City, Kansas

Years in practice: I have held faculty positions in the Orthopedic Surgery Department for 20 years but have been a researcher in orthopedic related subjects for over 30 years.

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

I have been reviewing for over thirty years and almost 18 years for JBJS.

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

Respond quickly to requests, commit real time to thoroughly consider the manuscripts, and get it done in a single day if possible.

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

Mostly scientific papers related to my research but occasionally classic French literature such as Stendhal’s Le Rouge et le Noir.

Learn more about the JBJS Elite Reviewers program.

Osteoarthritis Progression: Our Current Understanding

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.

Our understating of the progression pathways in knee osteoarthritis (OA) has evolved dramatically in recent years, as described in a recent review article.1 Over the past 2 decades, we have come to view the knee joint as an organ unto itself (with cartilage, synovium, bone, ligaments, and capsule). In the knee, we add to the mix the meniscus, which not only guides motion but is responsible for weight distribution on articular cartilage. Investigations into the etiology and progression of knee OA have merged joint mechanics with insights from studies of inflammation and immunology.

Woodell-May and Sommerfeld examine the process of knee OA as a wound-healing response. Triggered by damage-associated molecular patterns, the innate immune system is typically the first responder to this process. The acute phase in wound healing is short and involves infiltration of neutrophils. In response to neutrophil signals, monocytes migrate from the vessels and differentiate into macrophages, initially type I (inflammatory), which help form the granulation tissue seen in wound healing.

One take-home from the review article is that OA progression may be driven by the chronic inflammation associated with continuing efforts to heal. The back-and-forth between stimulating inflammation (M1 macrophages) and modulating inflammation (M2 macrophages) seems to be predominately driven from the synovium. In addition, specific receptors and intracellular kinases (such as toll-like receptors and mitogen-activated protein kinase) are upregulated in many OA samples.

M1 macrophages promote the elaboration of TNFα and IL-1 by synovial cells. Both cytokines are also active in rheumatoid arthritis (RA). Biologic treatment directed at either one of those cytokines can be effective in RA, but such treatment does not appear to be effective in OA. Over the past decade, the use of autologous conditioned serum (serum drawn off after blood is exposed to glass beads and incubated) has been studied in an attempt to reduce IL-1 activity. The conditioned serum also seems to affect TNFα and has shown some early promise in OA cases.

This burgeoning basic-science knowledge about OA has the potential to lead to disease-modifying treatments, which would revolutionize how orthopaedists approach OA treatment.

Reference
1. Woodell-May JE, Sommerfeld SD. Role of Inflammation and the Immune System in the Progression of Osteoarthritis. J Orthop Res. 2020 Feb;38(2):253-257. doi: 10.1002/jor.24457. Epub 2019 Sep 12. Review. PMID: 31469192

Elite Reviewer Spotlight: Harry McKellop

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: Harry A. McKellop

Affiliation:

Emeritus Professor in Residence

The UCLA and Orthopaedic Institute for Children Department of Orthopaedic Surgery

Los Angeles, CA

Years in practice: I have a PhD in Mechanical Engineering (Biomechanics). I was involved in orthopaedic research beginning in 1970 until I retired at the end of 2013.

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

I was invited to be a reviewer.

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

Provide constructive comments. Focus on those aspects of the research project that, if published, would be useful to the orthopaedic community, and advise the authors how to appropriately emphasize them in their manuscript.

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

Biographies of Napoleon Bonaparte and Leonardo da Vinci.

Learn more about the JBJS Elite Reviewers program.

Risk of Repeat Complications after Staged Bilateral TKA

Sometimes the findings of well-designed orthopaedic studies are unexpected and counterintuitive—and sometimes they are not. In the latter category are the important but unsurprising results from the Grace et al. database study in the February 19, 2020 issue of The Journal of Bone & Joint Surgery.

The authors set out to determine whether having a specific medical complication after a first total knee arthroplasty (TKA) increased the chance that the same complication would occur after a second TKA performed 90 to 365 days after the first one. Among the specific complications investigated were myocardial infarction (MI), ischemic stroke, respiratory complications, urinary complications, digestive complications, hematoma, deep vein thrombosis (DVT), and pulmonary embolism (PE).

Overall complications after either procedure were low—>90% of the >36,200 patients who underwent bilateral TKAs did not experience any complications during the study period. However, those who had a complication after the first TKA had a significantly higher likelihood of having the same complication after the subsequent, contralateral procedure. Expressed as odds ratios (ORs), the increased probabilities of the same complication recurring after the second procedure were as follows:

  • Myocardial infarction—OR, 56.63
  • Ischemic stroke—OR, 41.38
  • Hematoma—OR, 15.05
  • Urinary complications—OR, 11.19
  • PE—OR, 11.00
  • Respiratory complications—OR, 8.58
  • Non-MI cardiac complications—OR, 7.73
  • DVT—OR, 7.40

Noting that these findings do not imply causality, the authors nevertheless surmise that “the occurrence of complications after the first replacement likely reflects a burden of comorbidity that predisposes patients to a recurrence of the same complications after the second replacement.” Consequently, Grace et al. suggest that this data could be used to help guide shared decision-making with patients considering staged bilateral TKAs, and that these findings could help identify “a subgroup of patients who may benefit from…targeted optimization strategies prior to the second surgical procedure.”

So Far, Bundled Payments Not Affecting Patient Selection for Joint Replacement

Many people predicted that the mandatory “bundling” of payments for knee and hip arthroplasty by the Centers for Medicare and Medicaid Services (CMS) that began on April 1, 2016 in several US metropolitan areas would lead to  “cherry-picking” and ”lemon-dropping.” In other words, hospitals and surgeons wouldn’t take on more complex and sicker patients for joint replacement for fear that the bundled payment would be insufficient (lemon-dropping), and would instead select the healthier patients (cherry-picking). See related OrthoBuzz post.

In the February 19, 2020 issue of The Journal, Humbyrd et al. compare the characteristics of patients who underwent hip and knee replacement (HKR) from April to December 2015 with those of HKR patients during the same period in 2016, after CMS mandated the bundled-payment program in 67 metropolitan statistical areas (MSAs). The patients were matched so that those treated in bundled and non-bundled settings had similar socioeconomic backgrounds.

The matched groups included 12,388 HKR episodes in 40 bundled MSAs and 20,288 HKRs in 115 nonbundled MSAs. The authors also evaluated pre- and post-policy case-mix changes among 1,549 hip hemiarthroplasties, which are not subject to bundling, in the bundled MSAs.

Among patients who underwent HKR, Humbyrd et al. found no significant differences in patient characteristics—including race, dual Medicare-Medicaid eligibility, tobacco use, obesity, diabetes, and Charlson Comorbidity Index (CCI)—after the bundled-payment policy was implemented. Also, they found that patients in bundled MSAs undergoing hemiarthroplasty had significantly higher CCI values and were more likely to have diabetes than those who underwent HKR. This suggests that some surgeons opt for hemiarthroplasty over total hip replacement in less-healthy patients to avoid treating such patients under a bundled program.

From the MSA perspective, these results suggest that cherry picking and lemon dropping are not occurring in the short term. But we would do well as a profession to ensure that those controversial patient-selection practices are not happening at the individual surgeon level, and that the short-term results demonstrated here by Humbyrd et al. persist over the longer term. Even our sickest joint replacement patients deserve the best surgical care.

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

What’s New in Pediatric Orthopaedic Surgery 2020

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 OrthoBuzz summaries of these “What’s New” articles. This month, co-author Kelly Vanderhave, MD selected the 5 most clinically compelling findings from the more than 50 studies summarized in the February 19, 2020 “What’s New in Pediatric Orthopaedic Surgery.

ACL Reconstruction
—ACL reconstruction in pediatric patients continues to receive research attention. A recent review of >560 cases showed that soft-tissue grafts used in this population were twice as likely to fail (13%) as patellar tendon grafts (6%) (p <0.001).1

Septic Arthritis of the Hip
—A multicenter study identified the following independent risk factors for a repeat surgical procedure after initial arthrotomy for septic arthritis of the hip: presenting CRP of >10 mg/dL and ESR of >40 mm/hr, and the presence of osteomyelitis and MRSA.2

Adolescent Idiopathic Scoliosis
—A minimum 20-year follow-up of a cohort study evaluating 180 patients after observation, bracing, or surgical management of adolescent idiopathic scoliosis found the following:

  • In the observation cohort, 5 of 36 patients underwent a scoliosis surgical procedure as an adult.
  • In the bracing cohort, only 1 of 41 patients required an additional spinal surgical procedure.
  • In the surgical cohort, 7 of 103 patients required a revision surgical procedure.

At a mean follow-up of 30 years, there were no significant differences in patient-reported outcomes between the 3 cohorts.3

Infection after Spinal Deformity Surgery
—A retrospective study of >600 pediatric patients who underwent spinal deformity surgery identified 2 independent risk factors among 11 cases of deep surgical site infection that occurred >3 months after the procedure:

  • Nonidiopathic scoliosis (e.g., neuromuscular, congenital, and syndromic etiologies)
  • High volume of crystalloid administered during surgery (mean of 3.3 ±1.2 L in the group with surgical site infections vs 2.4 ±1.0 L in the infected group)

Redosing antibiotics intraoperatively after 3 hours did not significantly influence the risk of infection.4

Hip Dislocations in Infants with CP
—Among 11 patients (15 hips) with spastic cerebral palsy whose preoperative mean acetabular index was 29°, surgical hip reconstruction (a combination of open reduction, adductor tenotomy, femoral osteotomy, and/or pelvic osteotomy) yielded the following results at a mean follow-up of 40 months:

  • Mean migration index of 7%
  • Mean acetabular index of 22°
  • No instances of osteonecrosis
  • 90% achievement and maintenance of hip reduction in those who underwent open reduction with or without pelvic or femoral osteotomy.5

References

  1. Ho B, Edmonds EW, Chambers HG, Bastrom TP, Pennock AT. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop. 2018 Aug;38(7):388-92.
  2. Murphy RF, Plumblee L, Barfield WB, Murphy JS, Fuerstenau N, Spence DD, Kelly DM, Dow MA, Mooney JF 3rd. Septic arthritis of the hip-risk factors associated with secondary surgery. J Am Acad Orthop Surg. 2019 May 1;27(9):321-6.
  3. Larson AN, Baky F, Ashraf A, Baghdadi YM, Treder V, Polly DW Jr, Yaszemski MJ. Minimum 20-year health-related quality of life and surgical rates after the treatment of adolescent idiopathic scoliosis. Spine Deform. 2019 May;7(3):417-27.
  4. Du JY, Poe-Kochert C, Thompson GH, Son-Hing JP, Hardesty CK, Mistovich RJ. Risk factors for early infection in pediatric spinal deformity surgery: a multivariate analysis. Spine Deform. 2019 May;7(3):410-6.
  5. Refakis CA, Baldwin KD, Spiegel DA, Sankar WN. Treatment of the dislocated hip in infants with spasticity. J Pediatr Orthop. 2018 Aug;38(7):345-9.

Elite Reviewer Spotlight: Noam Shohat

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: Noam Shohat

Affiliation:

Sackler Faculty of Medicine, Tel Aviv University, Israel

Years in practice: Six Years

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

After several years of research, and once I gained knowledge in statistical analysis and study design, I reached out to the JBJS Editorial Board to become a reviewer.

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

Researchers devote themselves to their research; they spend much time and thought throughout the long process that ends with submission. I do my best to remember this in each review; I review only topics that I feel I have extensive knowledge in. I spend several hours examining each study and pay special attention to its design and analysis. Finally, I try to accept every review request in my field and I complete it as quickly as possible.

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

I try to keep updated in general medicine. I read the New England Journal of Medicine weekly. This also enhances my understanding on design and statistical analysis.

Learn more about the JBJS Elite Reviewers program.

MRI Can Detect “Invisible” Femoral Neck Fractures in Patients with Shaft Fractures

For more than 40 years, orthopaedic trauma surgeons have been interested in this fairly common fracture combination, which is often seen in polytrauma patients. We have long hypothesized that much of the energy that fractures the femoral shaft is dissipated, leaving many ipsilateral neck fractures nondisplaced and difficult to recognize on plain radiographs.

But the consequences of missing a femoral neck fracture can be devastating. For example, because the neck fracture pattern is often vertical (Pauwels type III), the risk of displacing the neck fracture during intramedullary nailing is very high. Achieving reduction and fixation of a displaced neck fracture near an intramedullary nail—either intraoperatively or postoperatively—is extremely challenging.

Because of these issues, some authors recommend a thin-cut CT series to identify nondisplaced ipsilateral neck fractures preoperatively, and this protocol has been shown to significantly reduce the delay in identifying such fractures. In the February 19, 2020 issue of The Journal, Rogers et al. from UTHealth in Houston show that even with thin-cut CT, the crack can be missed. These authors added to the protocol limited-sequence MRI that identifies these fractures with very high sensitivity and takes <10 minutes to perform.

In this study, among 39 acute, high-energy femoral shaft fractures, the authors identified 4 ipsilateral neck fractures with MRI that were not seen on CT. Despite exhibiting polytrauma, 89% of all indicated patients in this study were evaluated preoperatively with the limited-sequence MRI protocol, including those in traction and those treated initially with external fixation.

The findings from this study should prompt trauma surgeons practicing in high-volume centers to develop similar MRI protocols. It may also be possible to develop such protocols in lower-volume centers, but in those settings it is especially incumbent on the surgical team to recognize that this fracture combination occurs in a fairly high percentage of cases and to carefully scrutinize plain radiographs and consider thin-cut CT scanning of the ipsilateral hip. In addition, the potential for an ipsilateral nondisplaced femoral neck fracture should trigger increased use of fluoroscopy during intramedullary nailing of shaft fractures, so that concomitant neck fractures can be recognized and stabilized with screws before they become displaced.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Rotator Cuff Conundrums: JBJS Webinar-Feb. 24

Rotator cuff tears account for an estimated 4.5 million patient visits per year in the US, which translates into a $3 to $5 billion annual economic burden. Add to that the pain and disability associated with rotator cuff tears, and it’s understandable that many clinical questions arise regarding how best to help patients manage this common condition.

On February 24, 2020 at 8 pm EST, JBJS will host a complimentary 60-minute webinar focused on 2 frequently encountered rotator cuff dilemmas: surgical versus nonsurgical management, and surgical alternatives for irreparable cuff tears that don’t involve joint replacement.

Bruce S. Miller, MD, MS unpacks the findings from his team’s matched-pair analysis in JBJS, which revealed that patients receiving both surgical and nonsurgical management of full-thickness tears experienced pain and functional improvements—but that surgical repair was the “better of two goods.”

Some patients who opt for nonoperative management end up with a chronic, irreparable rotator cuff tear. Teruhisa Mihata, MD, PhD will present findings from his team’s JBJS study, which showed that, after 5 years, healed arthroscopic superior capsule reconstruction in such patients restored function and resulted in high rates of return to recreational sport and work.

Moderated by Andrew Green, MD of Brown University’s Warren Alpert Medical School, the webinar will feature additional expert commentaries. Grant L. Jones, MD will comment on Dr. Miller’s paper, and Robert Tashjian, MD will weigh in on Dr. Mihata’s paper.

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.

Seats are limited, so Register Today!

Elite Reviewer Spotlight: Robert Schenck

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: Robert Cumming Schenck, Jr., M My friends call me “Bob” or “Bobby”.

Affiliation:

University of New Mexico, Albuquerque, NM, USA

Years in practice: 29.  I have had 2 jobs in Orthopaedic Surgery.  My first decade of orthopaedic practice was in San Antonio at UTHSCSA (my thanks to Jim Heckman, MD) and my past 20 years have been in Albuquerque at the University of New Mexico (my thanks to Moheb Moneim, MD).  I became chair of Orthopaedics at UNM in 2006 and along with a fun sports medicine/trauma practice, continue as a leader servant to this day.

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

 Simply by invitation and being an academic orthopaedic surgeon.  I found it a good way to give back to the profession.

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

My advice is to be timely with reviews, candid but professional with opinions, and to focus on your area of expertise.  It is especially useful to review topics of interest as you will find the review a positive learning experience through which you can give back to our wonderful profession of orthopaedic surgery.  As an aside, when I accept a review, I create a folder with that title, export the specific manuscript PDF and create a blank review format with the identifying title of the manuscript.  This folder goes into my “to do” folder on my Mac Book Air and once completed is moved to my finished reviews.  Doing this step of downloading the manuscript PDF and starting my review format at the time of each invitation sets me up for success, not missing the deadline, and putting the project into a proper queue for thoughtful completion.  Lastly, when I fly, or watch sports, I clear out my “to do” folder!

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

Like most of us, I read a lot. I was fortunate as an adolescent on the Western Slope of Colorado to have minimal television exposure and have always read. Gratefully, my wife Trish and I have instilled this habit in our children and I have an unofficial adult Schenck Kid Book Club; most recently we read Howard Stern’s Comes Again, Truman Capote’s In Cold Blood, and in preparation for Quentin Tarantino’s recent movie Once Upon a Time in Hollywood, we read Vincent Bugliosi’s account of the Manson Family in Helter Skelter.  Outside of that club, I recently began reading James Fennimore Cooper’s Leatherstocking Tales and read Last of the Mohicans.

Reading and writing go hand in hand. I especially enjoy writing and editing my own fiction and non-fiction. As a result of this passion, I was asked to be editor of the University of New Mexico Medical Muse a few years back and I read/re-read all art submissions of poetry, fiction and non-fiction with my co-editor, Laura Hall. I recently published on Amazon/Kindle Juárez, an action novella starring a fictional FBI agent, Shandy Randall, working in the Southwest. The second installment of the Shandy Randall series, Snow Mass, is in preparation.  Self-publishing on Kindle was a blast and allowed me to learn a new avenue for publication. I highly recommend that process and adventure to all.

Learn more about the JBJS Elite Reviewers program.