Archive | August 2020

Thieme to Market JBJS Clinical Classroom in South Asia

The Journal of Bone and Joint Surgery, Inc. and Thieme Medical and Scientific Publishers have joined forces in a 5-year agreement that grants Thieme exclusive rights to market and license JBJS Clinical Classroom on NEJM Knowledge+ in South Asia, including India, Pakistan, Bangladesh, Sri Lanka, and Nepal. JBJS Clinical Classroom is an adaptive system for orthopaedic learning that individualizes learners’ experiences as their knowledge, skill, and confidence develops.

Throughout the Indian subcontinent, Thieme representatives will demonstrate and promote the many unique features of JBJS Clinical Classroom to orthopaedic residency programs, hospitals, medical schools, and pharmaceutical companies. Those features include:

  • Regularly updated, evidence-based content that is peer-reviewed by subspecialty content experts and approved by Clinical Classroom Editor Christopher Chiodo, MD
  • Custom algorithms that direct learners away from subjects in which they are proficient and toward weaker areas until all content is mastered
  • An automated “recharge” function to help learners retain previously learned content and to relearn things they may have forgotten

Thieme is an award-winning international medical and science publisher serving health professionals and students for more than 125 years. A similarly venerable organization, The Journal of Bone and Joint Surgery, Inc. is the publisher of JBJS, the most valued source of information for orthopaedic surgeons and researchers for over 125 years and the gold standard in peer-reviewed scientific information in the field.

Click here for more information about JBJS Clinical Classroom.

For more information about the JBJS-Thieme alliance, please contact Betsy Bellar at bbellar@jbjs.org.

Opioid Use Challenges and Solutions: JBJS Webinar-Sept. 23

Amid the current backdrop of opioid misuse, overdose, and addiction, conducting robust studies to investigate management of musculoskeletal pain is uniquely challenging. Last November, a JBJS-convened symposium, supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, explored those challenges, and from that meeting came a 12-article JBJS Supplement published in May 2020.

On Wednesday, September 23, 2020 at 8 PM EDT, a one-hour live JBJS webinar will focus on 2 of the most salient solutions arising from the symposium.

Jeffrey Katz, MD, MSc will examine how to overcome study-design challenges such as quantifying opioid use, confounding by indication, and distinguishing between nationwide “secular changes” in opioid prescribing and the true effects from studied interventions.

Seoyoung Kim, MD, ScD, MSCE will emphasize that careful attention to methods is crucial when designing and conducting observational studies based on claims databases and patient registries, because widely accepted definitions of many common terms, such as “persistent opioid use,” do not exist.

Moderated by James Heckman, MD, Editor Emeritus of JBJS, the webinar will feature additional expert commentaries on the two author-led presentations. Andrew Schoenfeld, MD will weigh in on Dr. Katz’s paper and Nicholas Bedard, MD will comment on Dr. Kim’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!

Hydrogel + Stem Cells Improve Disc Conditions in Goats

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.

One of the key changes leading to intervertebral disc degeneration is the loss of complex proteoglycans in the nucleus pulposus (NP), which leads to a loss of water avidity, physiologic dysfunction, NP tissue rigidity, and disruption of surrounding disc tissues. In humans, these changes can begin as early as the second decade of life. One of the difficulties in developing cellular therapies to address these changes is creating a hydrogel that can support effective delivery of mesenchymal stem cells (MSCs).

University of Pennsylvania researchers chemically induced degeneration in lumbar discs in adult male goats. After 12 weeks, some of the degenerating discs were injected with either a hydrogel alone (n=9 discs) or hydrogel with 10 million mesenchymal stem cells per ml (n=10 discs). The remaining discs received neither injection. Two weeks later, researchers analyzed disc height, hydrogel distribution, and MSC localization using green fluorescent protein (GFP) immunostaining.

After 12 weeks of disc degeneration, disc height was approximately 66% of pre-intervention levels. After 2 weeks of the treatment phase, researchers found an insignificant increase in height in the hydrogel-alone discs, and a significant 7.6% height increase in the hydrogel-with-MSCs discs. Imaging revealed that the majority of hydrogel was located in the NPs of the treated discs.

Treated discs exhibited improved overall histological grade compared to untreated discs, but the improvement was significant only in discs treated with hydrogel + MSCs. The fact that GFP-positive MSCs were identified both in the hydrogel itself and in the surrounding NP tissue suggests that MSCs migrated beyond the injection site.

The question remains whether we can similarly improve physiology in the wide spectrum of degenerative disc disease experienced by humans. Let’s hope that future investigations yield positive findings.

Teamwork Necessary When Treating Patients with Syringomyelia + Scoliosis

Most orthopaedic spine surgeons and neurosurgeons have come to understand that syringomyelia plays a role in some cases of scoliosis, and that the spinal-cord condition may increase the risk of cord injury during deformity-correction surgery. In the August 19, 2020 issue of JBJS, Tan et al. investigate whether radiographic and clinical outcomes after 1-stage posterior spinal fusion to correct scoliosis secondary to syringomyelia differ between patients with syringomyelia related to Chiairi-I malformation (CIM) and those with idiopathic syringomyelia.

The short answer is “no.” Although researchers found larger preoperative syringeal parameters in the CIM group, up through 2 years after scoliosis-correction surgery, they detected no significant between-group differences in coronal/sagittal parameters or in scores from the 5 domains of the Scoliosis Research Society-22 questionnaire. Moreover, the preoperative neurological status and intraoperative neuromonitoring signals were similar in both groups.

In commenting on these findings, Kent A. Reinker, MD, points out that patients who had received preoperative neurological treatment for the syrinx were excluded from the study, so “the results … do not necessarily apply to patients who have had neurological intervention prior to scoliosis surgery.”  He strongly recommends that all patients with a syrinx be referred to a neurosurgeon for evaluation prior to any scoliosis surgery, concluding that “a working partnership between orthopaedic surgeons and their neurological colleagues is important when assessing these patients.”

What’s New in Limb Lengthening and Deformity Correction 2020

Every month, JBJS delivers 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, Andrew G. Georgiadis, MD, co-author of the August 19, 2020 What’s New in Limb Lengthening and Deformity Correction,” selected the five most clinically compelling findings from among the more than 50 noteworthy studies summarized in the article.

Congenital Limb Deficiencies
A study of 42 children with severe fibular hemimelia found that levels of psychosocial adjustment and health-related quality of life were comparable among those who underwent staged reconstruction and those who underwent amputation, at a minimum of 2 years after treatment.

Congenital Dysplasia
–A study evaluating long-term outcomes of 34 patients who were treated with the Charnley-Williams procedure for congenital pseudarthrosis of the tibia found high rates of refracture after initial union, and that failure to operate on the fibula at the time of index surgery resulted in poor outcomes. On a more positive note, 10 of the 13 refractures healed upon retreatment.

Trauma
–A series of 14 patients with aseptic nonunion of the femur or tibia underwent long-bone compression with magnetic lengthening nails programmed “in reverse.”1 The nails shortened by 6.7 mm and the bones shortened by an average of 3.1 mm. Union was achieved in 13 of 14 cases.

Limb Lengthening
–In a study comparing motorized internal lengthening with external fixation for humeral lengthening,2 ultimate lengthening parameters were comparable, but motorized lengthening mitigated pin-site complications and allowed for reuse of the implant.

Pin-Site Management
–A randomized trial of 114 patients with external fixators concluded that there is no role for antiseptic preparations in routine pin care.3 Neither the antiseptic preparation used nor daily dressing changes affected the pin-site infection rate.

References

  1. Fragomen AT, Wellman D, Rozbruch SR. The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report. Arch Orthop Trauma Surg. 2019 Nov;139(11):1551-60. Epub 2019 Jun 19.
  2. Morrison SG, Georgiadis AG, Dahl MT. Lengthening of the humerus using a motorized lengthening nail: a retrospective comparative series. J Pediatr Orthop. 2019 Sep 23. Epub 2019 Sep 23.
  3. Subramanyam KN, Mundargi AV, Potarlanka R, Khanchandani P. No role for antiseptics in routine pin site care in Ilizarov fixators: a randomised prospective single blinded control study. Injury. 2019 Mar;50(3):770-6. Epub 2019 Jan 23.

Sustained Fevers After Spinal Fusion: A Sentinel for Infection?

Postoperative fevers occur frequently. During the first 2 to 3 days after surgery, these fevers are often due to atelectasis or the increased inflammatory response that arises from tissue injury during surgery. However, persistent postoperative fevers should be cause for concern. In the August 19, 2020 issue of The Journal, Hwang et al. examine the relationship between sustained fevers after spine instrumentation and postoperative surgical site infection.

The authors retrospectively reviewed 598 consecutive patients who underwent lumbar or thoracic spinal instrumentation. They excluded patients who underwent surgery to treat tumors or infections and those with other identified causes of fever, such as a urinary tract infection or pneumonia. Sustained fevers were defined as those that began on or after postoperative day (POD) 4 and those that started on POD 1 to 3 if they persisted until or beyond POD 5.

Sixty-eight patients (11.4%) met the criteria for a sustained fever after spinal instrumentation. Nine of those 68 (13.2%) were diagnosed with a surgical site infection. Of the 530 patients who did not have a sustained fever, only 5 (0.9%) developed a surgical site infection (p<0.001 for the between-group difference).

Further analysis revealed 3 diagnostic clues for surgical site infections among the patients with sustained fevers:

  • Continuous fever (rather than cyclic or intermittent)
  • Levels of C-reactive protein (CRP) >4 mg/dL after POD 7
  • Increasing or stationary patterns of CRP level and neutrophil differential

In addition, the authors found that CRP levels >4 mg/dL between PODs 7 and 10 had much greater sensitivity for discriminating surgical site infection than gadolinium-enhanced magnetic resonance imaging data obtained within 1 month of the surgical procedure.

Although a vast majority (87%) of patients with sustained postoperative fevers in this study did not develop an infection, persistent fever after spine instrumentation surgery is something to be mindful of. The authors describe their findings as “tentative” and advise readers to interpret them with caution. Those caveats notwithstanding, I consider this information to be valuable because it might help prevent delays in the diagnosis of a potentially serious perioperative complication.

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

Drug to Improve Tibial Shaft Fracture Healing Fizzles

In our ongoing attempt to identify pharmacologic interventions that improve fracture healing, the sclerostin inhibitor romosozumab is a logical candidate, as it has been shown to decrease bone resorption, improve bone healing in animal and human studies, and reduce the prevalence of some fragility fractures in postmenopausal women. In the August 19, 2020 issue of The Journal, Bhandari et al. present the results of a randomized trial comparing romosozumab to placebo in the healing of tibial diaphyseal fractures treated with intramedullary (IM) nails. Tibial shaft fractures are common in adults, but even after IM nail fixation there is a significant rate of healing failure and subpar functional outcomes with this fracture type.

The study by Bhandari et al. was very well designed and conducted with high-quality data collection. In terms of the primary outcome—median time to radiographic healing—there was no significant difference between the placebo group (n=100) and 9 romosozumab groups (n=293 total, testing 3 different dose levels and 3 different frequencies). Additionally, analysis revealed no differences between placebo and romosozumab groups in median time to clinical healing or in changes in physical function from baseline. (See related OrthoBuzz post about a recent randomized trial investigating romosozumab for hip fractures.)

Kudos to Amgen for funding the trial and for allowing the 66-center, international academic consortium that conducted it to publish the results, warts and all. Such negative findings appropriately inform decisions about which compounds to investigate and about study designs for retesting the same compounds. For example, Bhandari et al. encourage further study of romosozumab in tibial-fracture patients at high risk of poor fracture healing, such as those with diabetes or patients undergoing treatment with corticosteroids.

We are likely to see many such “failures” in the search for pharmacological adjuncts to improve fracture healing, but it seems our orthopaedic community has laid out a clear roadmap for studying this important question further.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Treating Developmental Hip Dislocations Diagnosed after Walking Age

There is a wry saying in academic medicine that “nothing ruins good results like long-term follow-up.” But long-term follow-up helps us truly understand how our orthopaedic interventions affect patients. This is especially important with procedures on children, and the orthopaedic surgeons at the University of Iowa have been masterful with long-term outcome analysis in pediatric orthopaedics. They demonstrate that again in the August 5, 2020 issue of The Journal, as Scott et al. present their results comparing outcomes among 2 cohorts of patients who underwent treatment for developmental hip dislocations between the ages of 18 months and 5 years—and who were followed for a minimum of 40 years.

Seventy-eight hips in 58 patients underwent open reduction with Salter innominate osteotomy, and 58 hips in 45 patients were treated with closed reduction. At 48 years after reduction, 29 (50%) of the hips in the closed reduction cohort had undergone total hip arthroplasty (THA), compared to 24 (31%) of hips in the open reduction + osteotomy group. This rate of progression to THA nearly doubled compared to previously reported results at 40 years of follow-up, when 29% of hips in the closed reduction group and 14% of hips in the open reduction group had been replaced.

In addition, the authors found that patient age at the time of reduction and presence of unilateral or bilateral disease affected outcomes. Patients with bilateral disease who were treated at 18 months of age had a much lower rate of progression to THA when treated with closed reduction, compared to those treated with open reduction—but the opposite was true among patients with bilateral disease treated at 36 months of age. Treatment type and age did not seem to substantially affect hip survival among those with unilateral disease.

I commend the authors for their dedication to analyzing truly long-term follow-up data to help us understand treatment outcomes among late-diagnosed developmental hip dislocations in kids. Long-term follow-up may “ruin” good results, but it gives us more accurate and useful results. And, in this case, the findings reminded us how important it is to diagnose and treat developmental hip dislocations as early in a child’s life as possible.

Read the JBJS Clinical Summary about this topic.

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

Electronic Portal Usage among Orthopaedic Patients

Physician groups and hospitals have come to rely on electronic patient portals (EPPs) for many things, including appointment scheduling and reminders, delivery of test results, and pre- and post-visit information gathering from patients. Most of the research into the clinical efficacy and cost-effectiveness of EPPs has taken place in primary care and internal medicine settings. But in the August 5, 2020 issue of The Journal of Bone & Joint Surgery, Varady et al. examine the benefits of EPP use among patients undergoing orthopaedic procedures of various types. In the process, they also uncover racial and socioeconomic disparities in the use of EPPs.

The retrospective review of >18,000 patients (average age of 56.9 years) undergoing an orthopaedic procedure at 2 Boston-area academic hospitals found a veritable 50-50 split between those who used the EPP and those who did not. Relative to white patients, African-American and Hispanic patients were significantly less likely to use the EPP. Other demographic factors associated with portal nonuse were non-English speaking, male sex, low income, and having less than a college education.

Multivariable regression analysis demonstrated that, relative to EPP nonuse, EPP use was associated with significantly lower no-show rates, increased odds of completing one or more patient-reported outcome measures (PROMs), and improved overall patient satisfaction. The degree of after-surgery functional improvements measured with PROMs was the same among EPP users and nonusers.

The authors home in on the benefits of the 27% reduction in missed appointments this study divulged. First and foremost, missed appointments have been shown to negatively affect patient outcomes. On the provider side, no-shows increase staff frustration and cost time and money. (The 2 hospitals realized a combined estimated $200,000 in savings over 1 year from the reduction in no-shows.) Consequently, Varady et al. say that “the benefit of reducing missed appointments alone may be sufficiently strong to warrant efforts to increase EPP enrollment.”

Increased efforts among orthopaedic office staff and clinicians to enroll patients in portal usage during their hospital stay or during pre- or postoperative visits could also help address the disparity issue. “These results have important implications for the orthopaedic surgery community in…achieving more equitable care,” the authors conclude.

Less Drinking/Smoking Associated with Fewer Hip Fractures

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS in response to a recent study in JAMA Internal Medicine.

Hip fractures are an important cause of morbidity and mortality among the elderly population worldwide. However, age-adjusted hip fracture incidence has decreased in the US over the last 2 decades. While many attribute the decline to improved osteoporosis treatment, the definitive cause remains unknown. A population-based cohort study of participants in the Framingham Heart Study prospectively followed a cohort of >10,000 patients for the first hip fracture between 1970 and 2010.

The age-adjusted incidence of hip fracture decreased by 4.4% per year during this study period. That decrease in hip fracture incidence was coincident with a decrease over those same 4 decades in rates of smoking (from 38% in 1970 to 15% by 2010) and heavy drinking (from 7% to 4.5%), with subjects born more recently having a lower incidence of hip fracture for a given age. Meanwhile, during the study period, the prevalence of other hip-fracture risk factors–such as being underweight, being obese, and experiencing early menopause–remained stable.

This study’s findings should be interpreted in light of 2 major limitations. First of all, there was a lack of contemporaneous bone mineral density data across the study period; secondly, all the study subjects were white. Nevertheless, these findings should encourage physicians to continue carefully managing patients who have osteoporosis and at the same time caution them against smoking and heavy drinking.

Shahriar Rahman, MS is an assistant professor of orthopaedics and traumatology at the Dhaka Medical College and Hospital in Bangladesh and a member of the JBJS Social Media Advisory Board.