Archive | March 2020

COVID-19 Rallies the Orthopaedic Community: Singapore’s Experience

The mind and heart of almost everyone on the planet are now focused to some extent on COVID-19. In the first of what will be a series of fast-tracked JBJS articles about how orthopaedic surgeons are helping mitigate the pandemic, Liang et al. describe orthopaedists’ early experiences in Singapore, where the first case of COVID-19 was confirmed in a tourist from Wuhan, China on January 23, 2020.

Singapore has had a nationwide outbreak-response system (called DORSCON, for Disease Outbreak Response System Condition) since the SARS crisis of 2003 (see Figure). Immediately after the first evidence of community spread of the virus on the island, on February 7, 2020, the Ministry of Health raised the DORSCON status to Orange, which triggered the following outbreak-control measures:

  • Ramping up of contact tracing
  • Mandatory 14-day quarantining of those in close contact with people who had confirmed infections
  • A 2-week mandatory leave of absence for healthcare workers with recent travel histories to China
  • Compulsory, twice-daily temperature screenings of all healthcare workers

The COVID-19-driven changes in orthopaedic practice revolved around 2 strategies:

  • Clinical Urgency
    • Musculoskeletal trauma and tumor patients were operated on as scheduled, but elective surgical cases were postponed to free up beds for confirmed or suspected COVID-19 patients.
    • Orthopaedists were encouraged to consider temporary pain-relieving measures (such as corticosteroid injections or nerve-root blocks) for patients with severe pain whose surgeries were postponed.
  • Patient and Healthcare-Worker Protection
    • Clinicians have been advised to prolong the duration between nonurgent follow-up appointments. All patients attending outpatient clinics are screened for risk factors and have their temperatures checked. Febrile patients are moved to the emergency department for further evaluation.
    • Orthopaedic teams wear surgical masks for all patient encounters and practice strict hand-hygiene practices.
    • When evaluating orthopaedic patients suspected of or diagnosed with COVID-19, all staff wear full personal protective equipment. Whenever possible, such evaluations take place in pressure-negative isolation units, and these patients are co-managed with infectious-disease colleagues.
    • If surgery on a suspected or confirmed COVID-19 patient is needed, it is performed by a dedicated orthopaedic contamination team; these teams are segregated from the rest of the staff to minimize the risk of cross-contamination.

Technology Tools for Training
Telemedicine and telerehabilitation have helped ensure the quality of patient care in Singapore, and technology is also being used to keep orthopaedic training going. Because all interhospital rotations and in-person combined teaching programs have been suspended, residency training programs are relying on videoconferencing platforms for scheduled teaching sessions. For trainees who engage with instructional videos or webinars, faculty members follow up with online discussions.

As residents take shifts in the emergency department to assist with COVID-19 screening, they learn important lessons in management of limited resources and “softer” skills such as empathy and teamwork.

Liang et al. conclude with this admonition to orthopaedic surgeons everywhere: “Stay vigilant even when reviewing low-risk elective patients; be champions of good hygiene practices, and be open-minded in the adoption of novel workplace technologies.”

THA in the Very Young: Midterm Results

Orthopaedic surgeons work hard to find good alternatives to total hip arthroplasty (THA) in patients <50 years old. That’s because the high functional demands and longer remaining lifespan in these patients can result in excessive wear of the bearing surfaces and loosening of the components—both of which have been documented in multiple publications. But what happens when THA is the most viable solution for a posttraumatic or congenital hip problem in a very young patient because arthrodesis or other osteotomies are not feasible?

In the March 18, 2020 issue of The Journal, Pallante et al. report medium-term outcomes of THA in 78 patients who were ≤20 years of age at the time of surgery, with follow-ups ranging from 2 to 18 years. The findings included the following:

  • 10-year survivorship for reoperation of 95.0%
  • 10-year survivorship for revision of 97.2%
  • 10-year survivorship for complications of 89.5%

Overall, the linear articular wear averaged 0.019 mm/yr in the ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene bearings studied, and the average modified Harris hip score in the cohort was 92.

However, despite these impressive clinical and survivorship outcomes, I advise orthopaedists not to lower their resistance to performing THA on these very young patients, many of whom present with hip problems caused by deforming conditions such as Legg-Calve-Perthes disease. We really need 30 to 40 years of outcome data to truly  understand what happens with function, revision rates, and wear characteristics in this population. Having said that, I am confident that this group from Mayo will continue reporting on this patient cohort at 5- to 10-year intervals, so that the worldwide orthopaedic community can keep learning from this experience.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Journal Club Resident Spotlight: Carl Herndon

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The purpose of this program is to promote career-long skills in evaluating the orthopaedic literature as it relates to practice decision making among orthopaedic residents. Click here for more information about the grant program.

Name: Carl Herndon, MD

Affiliation: Columbia University Medical Center, New York, NY

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

We recently had a journal club focusing on adult joint reconstruction, and discussed different fixation strategies of implants (broadly cement vs cementless fixation). We evaluated the following 3 studies:

Stea S, Comfort T, Sedrakyan A, Havelin L, Marinelli M, Barber T, Paxton E, Banerjee S, Isaacs AJ, Graves S. Multinational comprehensive evaluation of the fixation method used in hip replacement: interaction with age in context. The Journal of bone and joint surgery. American volume. 2014 Dec;96(Suppl 1):42-51.

Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in total hip arthroplasty. JBJS. 2011 Mar 2;93(5):500-9.

Nam D, Lawrie CM, Salih R, Nahhas CR, Barrack RL, Nunley RM. Cemented versus cementless total knee arthroplasty of the same modern design: a prospective, randomized trial. The Journal of bone and joint surgery. American volume. 2019 Jul 3;101(13):1185.

Based on your journal club experiences, what are the top 3 characteristics of an engaging, enlightening journal club presentation?

1. Hand-on activities: We always lead off our journal club with a sawbones exercise where senior residents, fellows, and attendings lead junior residents through a topical saw bones. Great to get everyone thinking and a chance for everyone to learn.

2. Multilevel involvement: Having everyone there from interns all the way to senior attendings is critical as we evaluate the literature with different biases and can all learn together.

3. Atmosphere: Reading these articles and discussing them doesn’t have to be boring! Having food or snacks and scheduling it at the end of the day allows for a more laid-back vibe to learning that is conducive to discussion.

What advice about running a top-notch journal club program do you have for residents who will manage a Robert Bucholz Resident Journal Club Grant next year?

Plan it out in advance, and put dates on the calendar for everyone to know when it’s happening. Nothing worse than trying to do all this work and having no one show up!

Aside from orthopaedic content (journals and otherwise), what have you been reading lately?

Once a Runner by John L. Parker Jr. One of my favorite books.

Volume-Outcome Relationships in Reverse TSA

In an OrthoBuzz post from early 2016, JBJS Editor-in-Chief Marc Swiontkowski, MD observed the following about volume-outcome relationships in total hip and total knee arthroplasty: “the higher the surgeon volume, the better the patient outcomes.”

Now, in a national database analysis of >38,200 patients who underwent a reverse total shoulder arthroplasty (RSA), Farley et al. find a similar inverse relationship between hospital volumes of this increasingly popular surgery and clinical outcomes. Reporting in the March 4, 2020 issue of JBJS, they found a similarly inverse relationship between hospital volume and resource utilization.

This study distinguishes itself with its large dataset and by crunching the data into specific hospital-volume strata for each category of clinical outcome (90-day complications, 90-day revisions, and 90-day readmissions) and resource-utilization outcome (cost of care, length of stay, and discharge disposition).

Specifically, on the clinical side, Farley et al. found the following:

  • A 1.42 times increased odds of any medical complication in the lowest-volume category (1 to 9 RSAs/yr) compared with the highest-volume category (≥69 RSAs/yr)
  • A 1.38 times increased odds of any readmission in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥70 RSAs/yr)
  • A 1.88 times increased odds of any 90-day revision in the lowest-volume category (1 to 16 RSAs/yr) compared with the highest-volume category (≥54 RSAs/yr)

Here are the findings from the resource-utilization side:

  • A 4.03 times increased odds of increased cost of care in the lowest-volume category (1 to 5 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
  • A 2.26 times increased odds of >2-day length of stay in the lowest-volume category (1 to 10 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)
  • A 1.68 times increased odds of non-home discharge in the lowest-volume category (1 to 31 RSAs/yr) compared with the highest-volume category (≥106 RSAs/yr)

Farley et al. say hospital volume should be interpreted as a “composite marker” that is probably related to surgical experience, ancillary staff familiarity, and protocolized pathways. They “recommend a target volume of >9 RSAs/yr to avoid the highest risk of detrimental 90-day outcomes,” and they suggest that the outcome disparities could be addressed by “consolidation of care for RSA patients at high-performing institutions.”

Elite Reviewer Spotlight: Peter Cole

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 A Cole, MD, FAOA

Division Medical Director, HealthPartners Orthopaedics & Sports Medicine

Program Medical Director, HealthPartners Trauma Network

Orthopaedic Trauma Director, Regions Hospital

Professor, University of Minnesota

Affiliation:

Regions Hospital – HealthPartners, St. Paul, MN

University of Minnesota, Minneapolis, MN

Years in practice: Since 1998 – 21 years

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

I think the reviewer invitations began to arrive after I began thematic publishing back in the early 2000’s.  Thematic publishing means consecutive publications on the same topic.  My own publishing themes included minimally invasive fracture care, complex scapular trauma, and fracture pattern mapping for example. Perhaps, editors use this threshold of success in the peer review process as the qualification for a successful reviewer. I believe achievement in thematic publishing has more to do with being invited, than networking, committee or political positions, or being a nice person, though these things help.

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

Thoughtful, structured, scientific, timely reviews—period.  No one quality alone is good enough, not even 3 out of 4.  I review for three journals consistently, and others on a selective case by case basis.  I have rejected many offers to be a journal reviewer in order to protect the integrity of the main three I have chosen.  It is hard to turn down experts and friends in order to keep the main thing the main thing.

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

I read and study The Bible consistently, if not daily—as the primary source of wisdom and personal growth.  I enjoy books on entrepreneurialism, leadership, spiritual growth and an occasional biography.

Learn more about the JBJS Elite Reviewers program.

Are Tantalum Hip Implants Safe?

I have been told that daytime TV is punctuated by a continual stream of ads for personal-injury lawyers asking if you have been injured by a particular medication or medical device.  Since 2002, billions of dollars have been paid out in lawsuits over metal-on-metal hip replacements containing cobalt and/or chromium, the “loose” ions of which increase the risk for aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL)—which are sometimes referred to as “pseudotumors.” So orthopaedic surgeons understandably want to know more about the potential long-term implications of newer metal technologies such as tantalum.

“Trabecular Metal” is a trade name for tantalum-based bone-ingrowth material that is now quite common in acetabular cups and revision shells used for total hip arthroplasty (THA). In the March 4, 2020 issue of the The Journal, Brüggemann et al. investigated the safety of these tantalum components. They retrospectively reviewed blood tantalum levels in 30 patients who underwent primary THA with no tantalum components, 30 patients who received a tantalum cup during a primary THA, and 84 patients who received a tantalum shell during a revision. Tantalum levels in 59 blood-donor volunteers served as controls. The authors also measured subsets of lymphocytes (CD8+ and CD4+ T-cells) that are thought to be associated with the immunologic cascade causing ALVAL.

At an average follow-up of 4 years, Brüggemann et al. found that median tantalum concentrations were 0.051 µg/L  in those receiving primary tantalum implants and 0.05 µg/L in those receiving primary implants without tantalum. (The “detection limit” for tantalum used in this study was 0.05 µg/L.) Patients receiving revision tantalum shells had median serum tantalum levels of 0.091 µg/L.  Time since surgery did not affect tantalum levels.

The authors also found a weak negative correlation between increased tantalum concentration and lower concentrations of CD8+ T-cells. Clinically, none of the hips in this series was deemed loose, and the Harris hip scores among all subjects were good to excellent.

It seems that with stable tantalum implants, any increase in serum concentrations of tantalum is small, but we don’t yet know the longer-term implications of these small increases. While it’s also reassuring that the lymphocyte activation associated with ALVAL does not seem to occur with these tantalum implants, I agree with the authors’ conclusion that this study “cannot exclude the possibility that even low tantalum concentrations confer a risk to patients’ health.”  Clearly, longer-term studies are needed.

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

Elite Reviewer Spotlight: Arvind von Keudell

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: Arvind von Keudell, MD

Affiliation:

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

Years in practice: 1.5 years

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

The editor-in-chief, Dr. Marc Swiontkowski, kindly invited me to review for his journal. Other journals have reached out to me either due to personal connections or due to my previous publications in their journal.

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

The most important advice is to take the time to diligently read the paper at least 3 times. First to get a sense of what the authors are trying to convey, second to assess the quality of the methods and the interpretation of their results and whether their discussion places the results in perspective to the current literature. In general, it might be helpful to provide constructive feedback for the authors.

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

I try to read research studies from other fields to gain perspective for my own research work and to improve my ability to review manuscripts. More specifically, I am interested in papers from specialties such as geriatric, rheumatology, endocrinology and anesthesia as well as topics such as global surgery, artificial intelligence and machine learning.

Learn more about the JBJS Elite Reviewers program.

Implant Prices are Main Cost Driver in Joint Replacements

Orthopaedic surgeons have long been aware of the role that implant prices play in the total cost of care for arthroplasty procedures, but methodical breakdowns of implant costs in relation to the cost of other aspects of care have generally been lacking. In the March 4, 2020 issue of The Journal, Carducci et al. detail the impact of implant costs on the total cost of care in a study of 6 lower- and upper-extremity arthroplasty types performed at a single, high-volume orthopaedic specialty hospital.

Using a uniform method called time-driven activity-based costing, the authors calculated the total costs of >22,200 inpatient primary total joint arthroplasties, and then broke down those total costs by categories, including implant price and personnel costs. It was no surprise that, as a percentage of total cost, implant costs were highest for low-volume surgeries (as high as 65% for total ankle arthroplasty) and lowest for high-volume procedures (e.g., 40% for total knee arthroplasty). Nevertheless, across the board, implant price was the most expensive component of total cost.

Implant prices are individually negotiated between a hospital and an implant supplier and are usually protected by nondisclosure agreements, so the data from this investigation may not match up with data from any other institution. Unfortunately, the future of implant-cost research will be tied to the complex issue of return-on-investment for implant-manufacturer stockholders as it relates to negotiations with individual hospitals and health systems.

The profound impact of implant price on the total cost of all the joint arthroplasties studied by Carducci et al. also begs the questions as to how “generic” implants (those not manufactured by the major orthopaedic producers) will ultimately influence the market—and whether “branded” implants, with their 30% to 50% markups, provide any functional benefit for patients. We will need further well-designed research to address those questions.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: In-Ho Choi

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: In-Ho Choi, MD, PhD

Affiliation:

Chung-Ang University Medical Center, Seoul, South Korea

Years in practice: 35 years

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

I have been reviewing manuscripts for JBJS for 7 years and reviewing for other orthopaedic journals for 23 years.

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

Try to provide constructive feedback that gives the authors both an opportunity and the means to improve the quality and clarity of the manuscript.

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

21 Lessons for the 21st Century by Yuval Noah Harari

Learn more about the JBJS Elite Reviewers program.