Archive | September 2020

Pandemic Postponements: How Long Will the Backlog of Elective Surgeries Last?

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent COVID-19 article in JBJS.

 At the beginning of the 2020 coronavirus pandemic, hospitals and health-care systems reassigned staff, facilities, and supplies away from nonessential services to cater to the rising number of COVID-19 patients. During that time, many elective surgeries were postponed until resources became available again and safety protocols were established. This situation has resulted in a growing backlog of postponed elective surgeries that has to be managed now, as elective surgery is re-emerging, and in the foreseeable future.

A Johns Hopkins University research team headed by Amit Jain used a Monte Carlo analysis model to answer 3 specific questions about the elective-surgery backlog in orthopaedics:

  • When will the health-care system return to nearly full capacity for performing elective surgery?
  • What will be the extent of the backlog?
  • How should health-care systems change to address the backlog?

The authors looked specifically at data regarding inpatient elective total joint arthroplasties and spinal fusions in the US.

Assuming that elective orthopaedic surgery resumed in June 2020 (which it did at some centers), Jain et al. estimated that it will take 7 months in a best-case scenario before the health-care system regains 90% of its pre-pandemic elective orthopaedic surgery capacity. That optimistic 7-month timeframe assumes a “growth velocity” of elective orthopaedic procedures of 50% ± 5%. Achieving that 90% level will take an estimated 12 months with a growth velocity of 30% ± 3%, and 16 months with a growth velocity of 20% ± 2%. Even in the optimistic first scenario, a backlog of >1 million surgeries is expected 2 years after the end of elective-surgery deferment.

The long-lasting impact of the postponement of elective surgeries means that planning to address the backlog needs to start immediately. Jain et al. offer several potentially helpful ideas from the engineering arena that could be translated to health care, including ways to scale up surgical “throughput.” But other notions, such as “queuing and buffering,” could exacerbate existing health care disparities, the authors point out. Whichever tactical approaches to addressing the backlog health-care systems use, the authors conclude that “strategic investments focusing on capacity expansion are crucial.”

Impact Science is a team of highly specialized subject-area experts (Life Sciences, Physical Sciences, Medicine & Humanities), who collaborate with authors, societies, libraries, universities and various other stakeholders for services to enhance research impact.

 Through research engagement and science communication, Impact Science aims at democratizing science by making research-backed content accessible to the world

“Inflation” and Bias in Letters of Recommendation

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to 2 recent studies in JBJS Open Access.

It’s that time of year when many of us write and review letters of recommendation (LOR) for orthopaedic residency applicants. LOR have always played a large part in the ranking and selection of applicants, and they may be weighed even more heavily during the upcoming “virtual-interview” season. Many applicants present remarkable objective measures of accomplishment, accompanied by 3 to 4 glowing LOR from colleagues. But can all these people really be that good? I am not the first to wonder whether “grade inflation” has crept into the writing of recommendation letters.

As letter writers, we fulfill two important, but potentially conflicting, roles:

  1. Mentors: We want to support the applicants who have worked with us.
  2. Colleagues: We want to be honest with our peers who are reviewing the applications.

In addition, this dynamic is now playing out in the context of our profession’s efforts to increase the racial and gender diversity of the orthopedic workforce. This begs the question as to whether there are differences in how we describe applicants based on race and gender.

To help answer that question, our research team analyzed LOR from 730 residency applications made during the 2018 match. Using text-analysis software, we examined race- and gender-based differences in the frequency of words from 5 categories:

  1. Agency (e.g., “assertive,” “confident,” “outspoken”)
  2. Communal (e.g., “careful,” “warm,” “considerate”)
  3. Grindstone (e.g., “dedicated,” “hardworking,” “persistent”)
  4. Ability (e.g., “adept,” “intelligent,” “proficient”)
  5. Standout (e.g., “amazing,” “exceptional,” “outstanding”)

We hypothesized that men and women would be described differently, expecting, for example, that agency terms would be used more often for describing men and communal terms more often for describing women.

Our hypothesis was almost entirely wrong. The agency, communal, grindstone, and ability words were used similarly for both male and female applicants. Standout words were used slightly (but significantly) more often in letters describing women. When comparing word usage in LOR for white candidates to those of applicants underrepresented in orthopedics, standout words were more commonly used in the former, and grindstone words were more commonly used in the latter. Interestingly, neither gender nor race word-usage differences were observed when LOR using the American Orthopaedic Association (AOA) standardized letter format were analyzed.

In a separate but related study, we looked at the scores given in each of the 9 domains of the AOA standardized letter of recommendation. These scores clustered far “to the right,” with 75% of applicants receiving a score of ≥85 in all domains. While I am certain that orthopaedic residency applicants are universally very talented all-around, this lopsided scoring distribution makes it very hard to differentiate among candidates. Furthermore, 48% of applicants were indicated as “ranked to guarantee match.” I suspect that the “ranked to guarantee match” recommendation is made more often than it should be. Again, this “inflation” makes it challenging for applicants to stand out – and may have especially important implications in this year’s virtual-interview environment.

What I take away from these two studies is that our natural tendency as orthopedic surgeons is to write effusively about our student mentees. Perhaps the differences in how we describe applicants based on their race and gender can be mitigated by using the AOA standardized letter format, but that format has a profound ceiling effect that makes it hard to discern the “cream of the crop.”

As a specialty, we are truly fortunate to have such excellent students vying to be orthopedic surgeons, and it is quite possible that nearly all of the applicants applying for our residency programs would make great orthopedic surgeons. However, it would help us to have a baseline measure of how we rate our students. Having some kind of benchmark against which to measure our past rankings and how they compare to those of our peers would help immensely.

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

Elite Reviewer Spotlight: Allan Gross

JBJS is pleased once again 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.


Allan Gross


Mount Sinai Hospital

Years in practice: 40

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


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

Be on time and give short reviews.

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


Learn more about the JBJS Elite Reviewers program.

The Importance of a “Well-Rounded” Hip

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.

Fifty years ago, the precise etiology of hip osteoarthritis (OA) was not clear. In 1976, Solomon proposed 3 potential causes of osteoarthritis in general:1

  1. Failure of essentially normal cartilage subjected to abnormal or incongruous loading for long periods
  2. Damaged or defective cartilage failing under normal conditions of loading
  3. Breakup of articular cartilage due to defective subchondral bone

In 1986, Harris expanded on this concept by noting that mild acetabular dysplasia and/or pistol grip deformity were associated with 90% of patients who had “so-called primary or idiopathic” hip OA.2 Harris further claimed that “when these abnormalities are taken in conjunction with the detection of other metabolic abnormalities that can lead to osteoarthritis of the hip,…it seems clear that either osteoarthritis of the hip does not exist at all as a primary disease entity or, if it does, is extraordinarily rare.”

Subsequently, acetabular dysplasia was defined as an acetabular shape where the lateral center edge angle (LCEA) was <25°, and the cam and pincer deformities were introduced as forms of acetabular dysplasia. Acetabular retroversion, as detected by the crossover sign seen in anterolateral hip radiographs, was recognized later, and Tonnis used CT imaging to determine acetabular and femoral anteversion.3

In 2020, investigators suspected that zonal-acetabular radius of curvature (ZARC) might play a role in hip-joint shape disorders.4 ZARC is the radius of curvature of the articular contact surface (from the margin of the fovea centralis to the acetabular rim), and the authors analyzed ZARC in anterior, superior, and posterior zones in subjects with normal, borderline, and dysplastic hips. (“Normal” was defined as LCEA of 25° to <40°; “borderline” as LCEA of 20° to <25°; and “dysplastic” as LCEA of <20°.) The 3-zone ZARC findings are summarized in the table below.

Mean Zonal-Acetabular Radius of Curvature (ZARC)

ZARC Zone Borderline Normal Dysplasia
Anterior 29.8 +/- 2.6 mm 28.0 +/- 2.2 mm 31.5 +/- 2.7 mm *
Superior 25.7 +/- 3.0 mm 25.9 +/- 2.2 mm 25.8 +/- 2.5 mm
Posterior 27.2 +/- 2.5 mm 26.4 +/- 1.9 mm 30.4 +/- 3.3 mm *

* P < 0.01

In this study, the severity of lateral undercoverage affected the anterior and/or posterior zonal-acetabular curvature. The take home message is that, absent metabolic abnormalities, acetabular and femoral head congruity and orientation are the driving forces in hip OA.


  1. Solomon L. Patterns of osteoarthritis of the hip. J Bone Joint Surg Br. 1976;58(2):176-83. Epub 1976/05/01. PubMed PMID: 932079.
  2. Harris WH. Etiology of osteoarthritis of the hip. Clinical orthopaedics and related research. 1986(213):20-33. Epub 1986/12/01. PubMed PMID: 3780093.
  3. Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am. 1999;81(12):1747-70. Epub 1999/12/23. PubMed PMID: 10608388.
  4. Irie T, Espinoza Orias AA, Irie TY, Nho SJ, Takahashi D, Iwasaki N, et al. Three-dimensional hip joint congruity evaluation of the borderline dysplasia: Zonal-acetabular radius of curvature. J Orthop Res. 2020;38(10):2197-205. Epub 2020/02/20. doi: 10.1002/jor.24631. PubMed PMID: 32073168.

Cost-Effectiveness of PRP for Knee OA Questioned

The cost-effectiveness analysis of platelet-rich plasma (PRP) for knee osteoarthritis by Rajan et al. in the September 16, 2020 issue of JBJS is accompanied by 105 references. That’s just one indication of the level of interest in this anti-inflammatory and pro-angiogenic orthobiologic. Current literature suggests that PRP is safe, but its clinical efficacy in musculoskeletal conditions has been hotly debated in the orthopaedic community.

Rajan et al. applied Markov decision analysis to a clinical scenario in which a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis (OA) undergoes either a series of 3 PRP injections and a 1-year delay to total knee arthroplasty (TKA), or TKA from the outset. Their primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs). In Markov analyses, if one treatment costs less and produces more QALYs than a comparative treatment, it is considered to be the “dominant” approach.

The authors found that, from a health-care payer perspective, PRP (at an estimated cost of $728 per injection in 2018 US dollars) was not cost-effective if it yielded only a 1-year delay of TKA. However, from a societal perspective (which considered both lost productivity and the need for unpaid caregiving associated with TKA surgery), PRP was cheaper over a lifetime because it delayed direct and indirect costs associated with TKA. The ICER for TKA at the outset was $4,175 per QALY, which is well below the predetermined willingness-to-pay threshold of $50,000. The authors emphasize that this favorable ICER reflects the improved quality of life after TKA compared with published results of PRP injections for knee OA.

Rajan et al. do specify a clinical scenario in which PRP may have a cost-effectiveness advantage over TKA: “…in a higher-risk patient population in whom the perioperative complication rates, TKA revision rate, or postoperative functional outcomes are projected to be worse.”

What’s New in Hip Replacement 2020

Every month, JBJS reviews 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, PhD, co-author of the September 16, 2020 What’s New in Hip Replacement,” selected the five most clinically compelling findings from among the 95 noteworthy studies summarized in the article.

Medical Comorbidities and Outcomes of Joint Arthroplasty
–Among 543 malnourished joint arthroplasty patients (with albumin levels <3.4 g/L), an intervention encouraging  a high-protein, anti-inflammatory diet shortened the length of hospital stay and lowered readmissions, relative to malnourished arthroplasty patients who did not receive the intervention.1

Surgical Factors and Outcomes of Total Hip Arthroplasty (THA)
–A multicenter, prospective study used propensity-score matching to compare THA performed with a direct anterior approach with THA performed with a posterolateral approach. Researchers found no patient-reported outcome differences at 1.5 months postoperatively or at ≥1 year up to 5 years.2

Periprosthetic Joint Infection (PJI)
A Musculoskeletal Infection Society workgroup published a recommendation for a 4-tier tool for reporting outcomes after surgical treatment of PJI. Proposed outcomes include infection control with no antibiotic treatment, infection control with suppressive antibiotic therapy, need for reoperation and/or revision and/or spacer retention, and death.

–A meta-analysis found only low-quality retrospective evidence supporting the practice of routinely applying intrawound vancomycin to reduce the rates of PJI. Authors called for a prospective randomized trial before adoption of this practice.3

Postoperative Urinary Retention
–A randomized controlled trial found that preoperative and perioperative administration of tamsulosin did not reduce the incidence of postoperative urinary retention after hip and knee arthroplasty. However, the study included a general male population rather than a higher-risk group.4


  1. Schroer WC, LeMarr AR, Mills K, Childress AL, Morton DJ, Reedy ME. 2019 Chitranjan S. Ranawat Award: elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor. Bone Joint J.2019 Jul;101-B(7_Supple_C):17-21.
  2. Sauder N, Vestergaard V, Siddiqui S, Galea VP, Bragdon CR, Malchau H, Elsharkawy KA, Huddleston JI 3rd, Emerson RH. The AAHKS Clinical Research Award: no evidence for superior patient-reported outcome scores after total hip arthroplasty with the direct anterior approach at 1.5 months postoperatively, and through a 5-year follow-up. J Arthroplasty.2020 Feb 12.
  3. Heckmann ND, Mayfield CK, Culvern CN, Oakes DA, Lieberman JR, Della Valle CJ. Systematic review and meta-analysis of intrawound vancomycin in total hip and total knee arthroplasty: a call for a prospective randomized trial. J Arthroplasty.2019 Aug;34(8):1815-22. Epub 2019 Apr 1.
  4. Schubert MF, Thomas JR, Gagnier JJ, McCarthy CM, Lee JJ, Urquhart AG, Pour AE. The AAHKS Clinical Research Award: prophylactic tamsulosin does not reduce the risk of urinary retention following lower extremity arthroplasty: a double-blinded randomized controlled trial. J Arthroplasty.2019 Jul;34(7S):S17-23. Epub 2019 Mar 20.

Elite Reviewer Spotlight: Thomas DeCoster

In honor of Peer Review Week, JBJS is pleased once again 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.


Thomas A. DeCoster, M.D.


University of New Mexico Albuquerque, NM

Years in practice: 35

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

JBJS by invitation from another reviewer (Dr. Tom Grace) across town.

Reviewing in general by invitation from Dr. Jody Buckwalter who instilled in me the value of the peer review process and reviewing manuscripts as a service to orthopedics and for personal advancement.

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

Review in a prompt scientific manner, focusing on basic concepts like logic.

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

Nick Faldo: A Swing for Life.  The arms connected to the chest for chip shots in particular.

Learn more about the JBJS Elite Reviewers program.

Save Time with JBJS Clinical Summaries

Developed with the busy musculoskeletal clinician in mind, JBJS Clinical Summaries are synopses of the current State of the Science for >150 common orthopaedic conditions in 10 subspecialty areas.

Curated by recognized orthopaedic authors, JBJS Clinical Summaries deliver clinically useful “mini-reviews” of the most recent findings, with direct links to supporting original content. You can also earn CME.

To see a list of all current Clinical Summaries, click here, or click on the links below for some specific samples.


Elite Reviewer Spotlight: James Tibone

In honor of Peer Review Week, JBJS is pleased once again 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.


James Tibone


Kerlan-Jobe Orthopedic Clinic

USC. Los Angeles, CA

Years in practice: 40

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

They needed reviewers for the Journal of Shoulder and Elbow Surgery in the American Journal of Sports Medicine when I first started in practice. I later became an associate editor for the Journal of Shoulder and Elbow Surgery which I did for 10 years. I was then asked to review for the Journal of Bone and Joint Surgery.

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

Study the methods of the manuscript carefully as this usually determines if the paper is acceptable for publication.

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

I read multiple orthopedic journals including arthroscopy, JBJS, JSES, AJSM, CORR, and JAAOS. For fun, I read Harlan Coben fictional novels which are mystery novels.

Learn more about the JBJS Elite Reviewers program.

Preop X-Rays Don’t Predict TKA Patient-Reported Outcomes

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from David Vizurraga, MD in response to a recent study in JBJS Open Access.

Whoever coined the phrase, “a picture is worth a thousand words” never treated a patient with knee osteoarthritis (OA). While knee OA is one of the most common conditions encountered in orthopaedic practice and its diagnosis and treatment are fairly straightforward, predicting the outcomes of total knee arthroplasty (TKA)—the definitive treatment for most cases of end-stage knee OA—can be challenging. The severity of OA on radiographs has long been debated as a tool to aid surgeons in predicting post-TKA outcomes and framing expectations for patients. In general, we tend to say, “The worse the x-ray, the better the patient-reported outcome,” and conversely, “The better the x-ray, the worse the patient-reported outcome.”

Lange et al. investigated this assumption in a study published in JBJS Open Access on July 9, 2020. The authors leveraged data from a 2-arm, randomized controlled trial that evaluated the role of “motivational interviewing” in enhancing rehabilitation following TKA. In their cohort analysis, Lange et al. compared pre- and postoperative WOMAC pain scores and KOOS activities-of-daily-living (ADL) scores with preoperative radiographic severity of knee OA, as measured by the Osteoarthritis Research Society International (OARSI) Atlas score. Among the 240 patients who had 2-year outcome measures and imaging available, the median preoperative OARSI score was 10 (on a scale of 0 to 18), and the authors defined “milder OA”  as an OARSI score of <10 and “more severe OA”  as a score of ≥10.

The researchers found a cohort-wide postoperative improvement in WOMAC pain and KOOS ADL scores of ~30 points, but they did not find any significant or clinically important differences in pain and function scores between patients with “milder OA” and “more severe OA.” The authors were also unable to demonstrate any correlation between radiographic severity and pain and function scores preoperatively.

Additionally, Lange et al. looked for associations between the WOMAC and KOOS improvements and 4 four other radiographic assessments of knee OA severity (Kellgren-Lawrence grade, compartment-specific OARSI score, compartment-specific joint-space-narrowing score, and 4-level OARSI score). Again, they failed to observe any clinically important postoperative differences in pain or function between the subjects with radiographically milder or more severe OA.

These findings provide further evidence that radiographs should represent only one piece in the puzzle of diagnosis and treatment planning for our patients with knee OA. To me, it’s worth noting that the study capitalized on data from a trial investigating motivational interviewing, which aims to improve outcomes by empowering patients—yet in the multivariable analysis that adjusted for several confounders, use of motivational interviewing was not among them. Still, the many aspects of outcome prediction following knee replacement are most definitely worthy and in need of continued investigation.

David Vizurraga, MD is a San Antonio-based orthopaedic surgeon specializing in adult hip and knee reconstruction and a member of the JBJS Social Media Advisory Board.