Archive | October 2020

Elite Reviewer Spotlight: Edward Schwarz

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.


Edward M. Schwarz, Ph.D.


University of Rochester, Rochester, NY, USA

Years in practice: 23

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

I have published over 300 peer reviewed articles.  I published my first JBJS paper in 2001.  I started reviewing papers for many journals, including JBJS, shortly after that.

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

If you publish peer reviewed articles, have research grants, and/or are a member of AAOS, you have an obligation to review JBJS papers in your field.  If you are a thought leader in your field, you are obligated to reach Elite status.

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

I am an expert in the fields of Orthopaedics, Immunology, Bone Biology and Rheumatology, and try to stay current with JBJS, CORR, JOR, A&R, AR&T and JBMR.  For leisure I read biographies and Wine Spectator.

Learn more about the JBJS Elite Reviewers program.

What’s New in Shoulder and Elbow 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 all such OrthoBuzz specialty-update summaries.

This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the >40 studies summarized in the October 21, 2020 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A prospective randomized study compared operative and nonoperative treatment of small and medium-sized chronic full-thickness rotator cuff tears. At 10 years, the outcomes of primary repair were superior to those of nonoperative treatment, but both groups improved significantly over time.

Anterior Shoulder Instability
–A randomized trial compared arthroscopic Bankart repair to arthroscopic washout in the treatment of a first-time anterior dislocation. Bankart repair was associated with lower recurrence rates, fewer revisions, and better maintenance of functional outcomes.

–A prospective study evaluated the amount of glenoid bone loss associated with a single instability event in young athletes (average age of 20 years).1 A first-time dislocation was associated with a 6.8% bone loss. In the setting of recurrent instability, total bone loss averaged 10.2% at the time of enrollment and 22.8% after a subsequent instability event.

Proximal Humeral Fractures in the Elderly
–A randomized controlled trial compared locking-plate fixation with reverse total shoulder arthroplasty in treating intra-articular displaced proximal humeral fractures in patients 65 to 85 years of age. At 2 years, Constant-Murley scores were significantly better in the reverse total shoulder arthroplasty group.

“Little League” Elbow
–A prospective MRI-based study of Little League baseball players aged 12 to 15 years2 found that 58% of the players had abnormal upper-extremity MRI findings, and that in 80% of those players, the MRI findings worsened with continued baseball play. The authors suggest that surgeons discourage year-round play in young baseball players.


  1. Dickens JF, Slaven SE, Cameron KL, Pickett AM, Posner M, Campbell SE, Owens BD. Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events. Am J Sports Med.2019 Apr;47(5):1082-9.
  2. Holt JB, Pedowitz JM, Stearns PH, Bastrom TP, Dennis MM, Dwek JR, Pennock AT. Progressive elbow magnetic resonance imaging abnormalities in Little League baseball players are common: a 3-year longitudinal evaluation. Am J Sports Med.2020 Feb;48(2):466-72. Epub 2019 Dec 4.

PROMs Analyzed after Aseptic Revision TKA

The current literature about revision total knee arthroplasty (rTKA) for aseptic causes is focused mainly on “doctorly” data such as complication rates and implant survivorship. Taking a different tack in the October 21, 2020 issue of JBJS, Siddiqi et al. report findings from a comprehensive evaluation of patient-reported outcome measures (PROMs) at baseline and 1 year following rTKA. The PROMs evaluated included KOOS-Pain, KOOS-Physical Function, KOOS-QOL, and Veterans Rand-12.

Here is a general summary of the findings:

  • Patients undergoing aseptic rTKA had overall improvements in pain and function scores at 1 year postoperatively.
  • Knee-related QOL improved nearly 30 points, but >50% of patients did not report improvement in their overall global health at 1 year.
  • Predictors of improved 1-year pain scores were older age, baseline arthrofibrosis, lower baseline pain, and non-Medicare/Medicaid insurance.
  • Predictors of improved 1-year function scores were baseline arthrofibrosis and female sex.
  • Larger mean pain-score improvements occurred in patients undergoing rTKA for implant failure and aseptic loosening; pain-score improvements were lower in patients undergoing rTKA for instability.

Although 31% of the 246 eligible patients were lost to follow-up and excluded from the final analysis, the authors say their findings “corroborate the overall quality and, most importantly, the value that aseptic rTKA provides to patients.” Perhaps the findings’ greatest value is their potential application in the shared decision-making process between surgeons and patients pondering an aseptic rTKA, and in helping set realistic patient expectations if the surgery is undertaken.

A Genetic Basis for Adhesive Capsulitis?

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.

Adhesive capsulitis (AC), colloquially known as frozen shoulder, is associated with conditions such as diabetes, cardiopulmonary disorders, stroke, Parkinsonism, and injury. However, many cases are idiopathic. Given the inflammatory nature of the condition, clinicians often administer intra-articular steroid injections in recalcitrant cases where physical therapy alone is too painful or nonproductive. Some cases, particularly in patients with diabetes, may require manipulation, brisement, or arthroscopic release.

To better understand the genetic basis of AC, investigators obtained punch tissue samples from the middle glenohumeral ligament and rotator cuff interval from AC patients undergoing arthroscopic release surgery (mean age of 53 years) and from a comparative group of patients undergoing arthroscopic surgery for shoulder instability (mean age of 24 years).1 The researchers performed RNA sequencing-based transcriptomics on the samples and, after identifying differentially expressed genes, they applied real-time reverse transcription polymerase chain reaction (RT-PCR) to obtain more detailed genetic data.

A total of 545 genes were differentially expressed. The top 50 were associated with extracellular matrix remodeling. Patient age and sex did not have a major influence on gene expression. The genes marked by overexpression (not necessarily protein expression) were genes for matrix metallopeptidase 13 and platelet-derived growth factor subunit B. Other suspects included the gene for metalloprotease 9 and COL18A1.

In the discussion, the authors comment on the association between AC and protein tyrosine kinase 2 (PTK2), also known as focal adhesion kinase (FAK). FAK activation is particularly sensitive to fibronectin and other integrins. Activated FAK also controls cell migration and focal adhesion assembly. These interesting associations may also shine light onto the etiology of other musculoskeletal diseases.


  1. Kamal N, McGee SL, Eng K, Brown G, Beattie S, Collier F, Gill S, Page RS.
    Transcriptomic analysis of adhesive capsulitis of the shoulder.
    J Orthop Res. 2020 Oct;38(10):2280-2289. doi: 10.1002/jor.24686. Epub 2020 Apr 17. PMID: 32270543

Elite Reviewer Spotlight: Kerr Graham

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.


Professor Kerr Graham


Royal Children’s Hospital

Murdoch Children’s Research Institute (MCRI)

University of Melbourne

Melbourne, Victoria, Australia.

Years in practice: 43

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

I think my first invitation to review for JBJS came after my first published paper in JBJS. That has been a similar pattern with other journals.

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

I consider reviewing to be a privilege and a serious academic responsibility. I try to give JBJS reviews the first/best part of my working day, after any urgent clinical matters. Early mornings are best when the hospital is quiet and competing demands are fewer. I remember well, being the young researcher avidly checking for a reply and a decision on a submitted paper. So, knowing that I have accepted the responsibility I try to discharge that responsibility as quickly as possible. This is for the efficiency of the journal’s operations and to show the hard-working authors my respect for their efforts.

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

The classics (Shakespeare, Dostoevsky, Dickens, Emerson, Thoreau) and a lot of Poetry (Heaney, Auden, Larkin, Whitman, Eliot, Dickinson). Travel books: anything by Paul Theroux dreaming about being able to travel again, post Covid-19.

Learn more about the JBJS Elite Reviewers program.

Postop Dexamethasone Cuts Opioid Use after AIS Surgery

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

Pain management is an important aspect of postoperative care after posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS). Opioid medications, while highly effective and commonly used for postoperative analgesia, have many well-documented adverse effects. Several recent studies have suggested that dexamethasone, a glucocorticoid, is an effective adjunct for postoperative pain management after many adult orthopaedic procedures, but its use after AIS surgery has not been well studied.

Beginning in 2017, doctors at Children’s Healthcare of Atlanta added dexamethasone to their postoperative pain control pathway for adolescent spinal-fusion patients. In the October 21, 2020 issue of The Journal of Bone & Joint Surgery, Fletcher et al. report findings from a cohort study that investigated the postoperative outcomes of 113 patients (median age of 14 years) who underwent posterior spinal fusion between 2015 and 2018. The main outcome of interest—opioid consumption while hospitalized—was determined by converting all postoperative opioids given into morphine milligram equivalents (MME).

Because dexamethasone entered their institution’s standardized pathway for this operation in 2017, it was easy for the authors to divide these patients into two groups; 65 of the study patients did not receive postoperative steroids, while 48 patients were managed with 3 doses of steroids postoperatively. Relative to the former group, the latter group showed a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME. Patients who received postoperative dexamethasone were also more likely to walk at the time of initial physical therapy evaluation. Notably, the authors found no differences between the groups with regard to wound dihescence or 90-day infection rates—2 complications that have been associated with chronic use of perioperative steroids.

In commenting on these findings, Amy L. McIntosh, MD from Texas Scottish Rite Hospital for Children writes that she was so impressed that she plans “on adding dexamethasone to our institution’s standardized AIS care pathway.”

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.

Detecting Pathogens in Pediatric Infections: Swab, Tissue, or Bottle?

Identifying the pathogenic microorganism in childhood osteomyelitis and septic arthritis is essential to tailoring appropriate treatment. But the traditional methods of swab and tissue culturing have subpar success rates in pediatric patients, identifying the pathogen in only 40% to 60% of cases. In the October 21, 2020 edition of The Journal, Shin et al. report their findings comparing microbial identification rates using pediatric blood culture bottles (BCBs), typical culture swabs, and tissue specimens.

Over 3 years, the authors prospectively collected intraoperative specimens from 40 pediatric patients (mean age of 7.2 years) who underwent surgery for a presumed osteoarticular infection. Half of the patients had received oral or intravenous antibiotics in the 3 weeks prior to surgery, while the other half had received intravenous cefazolin after culture specimens were obtained in the operating room. Intraoperative culture specimens were obtained in 3 different manners for all patients:

  1. Four 21-gauge needles were dipped into the infected fluid and were used to inoculate 4 pediatric BCBs – 2 aerobic and 2 nonaerobic.
  2. Two swabs were placed in direct contact with the infected tissue.
  3. Two solid tissue samples were collected and placed in 2 sterile containers.

In these 40 cases, the microbial identification rate of the BCB method was 68%, compared to 45% with the swab method and 38% with the tissue method—all statistically significant differences. In 9 patients (23%), the pathogen was only identified with the BCB method. No samples showed positive culture growth with the other 2 methods if the BCB culture was negative. Interestingly, in a subgroup analysis of 15 patients with methicillin-susceptible Staphylococcus aureus (MSSA), the authors found no difference in detection rates between the 3 methods, but in cases involving organisms other than MSSA, detection with BCBs was significantly higher than with both swab and tissue cultures.

The apparent superiority of BCBs to detect microbial organisms could be due to the characteristics of pediatric BCBs, which enhance microorganism growth in a small amount of liquid. Although there are some concerns that this enhanced BCB detection could lead to increased rates of false-positives from contaminants, I think the risk of false positives is a viable tradeoff if we can more quickly and accurately identify pathogens in pediatric infections. As Shin et al. emphasize, “Sequelae resulting from these infections are particularly unfortunate for pediatric patients.”

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

Elite Reviewer Spotlight: Cecilia Rogmark

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.


Cecilia Rogmark


Dept of Orthopaedics, Skane University Hospital, Lund University, Malmö, Sweden

Years in practice: 30

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

After publishing my first papers in the early 00’s, I was invited to review. At first by Acta Orthopaedica whose editors had knowledge of new “local” researchers in Scandinavia, then gradually by other international journals. I am not sure how JBJS’ eye fell on me, but I guess being active as a researcher (both in writing and at meetings), lecturer and having a good international network will help.

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

Be curious (or try to be curious) on the text you are about to read. And realize that you will learn something from the paper, maybe not the core results are that interesting, but you will find a grain of gold elsewhere in the text.  Such positive attitude makes the work easier!

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

The Gospel of Eels – A Swedish book on the secrets of the eel, giving both the facts and the fiction. Sounds a bit weird, but really amazing! Available in English I think, written by Patrik Svensson.

Learn more about the JBJS Elite Reviewers program.

Using Registries to Investigate Rare Diseases

There has been a huge worldwide effort over the last 2-plus decades to establish arthroplasty registries. Among the many advantages of such registries, advocates emphasize the potential detection of early failures associated with new implant designs and biomaterials. The large number of patients enrolled in most registries and the methodical capturing of data yield substantial statistical and research benefits.

Based on the successes of arthroplasty registries, parallel registries have been established for sports medicine (especially for shoulder and knee conditions and treatments), fractures, musculoskeletal tumors, and others. Although the focus has been on enrolling large numbers of patients with relatively common disorders or procedures, there have been less well-publicized efforts to create smaller registries of rarer diseases.

In the October 21, 2020 issue of The Journal, Forman et al. use the 8-site Congenital Upper Limb Differences (CoULD) registry to report on associations between congenital deficiency of the radial aspect of the forearm in 259 patients (383 involved limbs) and thumb hypoplasia. Two findings stood out to me:

  • The severity of radial deficiency was correlated with the severity of thumb deficiency.
  • Compared with subjects who had no diagnosed syndromes, patients with concomitant syndromes (such as VACTERL and Holt-Oram) were twice as likely to have bilateral deficiency and 2.5 times as likely to have radial and thumb deficiencies as opposed to thumb deficiency alone.

In addition to reinforcing findings from previous single-institution studies, these data from Forman et al. will help surgeons counsel parents, determine treatment approaches, and establish frameworks for following patient outcomes after both surgical and nonsurgical treatment. It is my hope that other clinician-researchers with interest in understanding and managing rare conditions will establish similar registries to benefit these smaller but no-less-important groups of patients and families.

Click here to read the JBJS Clinical Summary on Congenital Hand Differences.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Elite Reviewer Spotlight: David Ring

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.


David Ring


Dell Medical School at The University of Texas at Austin, Austin, TX

Years in practice: 20

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

I’ve been involved in research since medical school, helped my mentors such as Jesse Jupiter with reviews, and was given opportunities to review starting in residency. 

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

Get curious.  Each study tells a story.  First about the author’s values and concerns and how they arrived at their question.  Then about the scientific methods employed.  And whether the data and analysis are helpful to you and your patients.

Take it seriously and be generous.  Most orthopedic research is done by volunteers that want to make a difference.  Be generous and constructive in your assessments.  Also, realize that if there is an error or misinterpretation there is a potential for harm. Start with a set of base principles for health and make sure the manuscript meets up with those.

Reviewing is a civic duty that makes me a better scientist.  I learn so much from reviewing.

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

After finishing White Fragility, I moved on to The Broken Heart of America.  As a white male I have privilege and it’s helpful to know that privilege came from violence and by design.  I want to do my part to undo that and make amends.  I’m also reading The Social Animal, one of many bestselling books that serve as instruction manuals for your mind.  The gist is that the unconscious and irrational are more impactful than the rational.  My favorite in this genre is The Invisible Gorilla.

Learn more about the JBJS Elite Reviewers program.