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Introducing the OrthoJOE Podcast: 2 Editors, 2 Coffees, and 2 Times the Evidence

JBJS EditorialPodcasts are an increasingly important mode of communication across many segments of society. Our field was perhaps a bit slow to catch on to this movement, but our attention has been awakened. In the Orthopaedic Forum section of this issue, Jella et al. evaluate the growth of podcasts over the previous 9 years within the field of orthopaedic surgery. Of the 94 podcasts that met the inclusion criteria, 62 remained active in the fall of 2020. The pace of introduction of new podcasts in our field has now reached 1 per month.

In collaboration with OrthoEvidence (www.myorthoevidence.com) and its Editor-in-Chief Mohit Bhandari, JBJS (www.jbjs.org) launched a new podcast in January 2021. We have named the podcast OrthoJOE, with the J coming from JBJS and the OE coming from OrthoEvidence. We find the name to be highly relevant, with both of us enjoying fresh coffee while recording these podcasts together every other Tuesday morning. The format of the podcast is highly conversational; some episodes are topical (for example, we recently discussed how our publications managed the explosion of submissions related to COVID-19), whereas others are based on new articles that have appeared in our own publications. The goal, however, is a simple one: to provide insights derived from evidence on top trending issues in OrthoEvidence and JBJS. Although Jella et al. found that 95.7% of active podcasts employ an audio-only format, we are in the process of creating a video version of the podcast that will be available on the JBJS and OrthoJOE websites. Our target audience is international, and our goal is to discuss topics that will be relevant to the worldwide orthopaedic community. As we evolve, we intend to invite guests to participate in topic-based discussions. We also plan to introduce a “mailbag” feature, during which we will discuss audience feedback regarding the opinions that we have expressed during previous episodes. You can listen to OrthoJOE at http://orthojoe.castos.com/ or subscribe through iTunes or wherever you get your podcasts. We invite you to tune in and are interested in your feedback and ideas for discussion. Many thanks in advance.

Mohit Bhandari, MD, PhD, FRCSC
Editor-in-Chief, OrthoEvidence
Marc Swiontkowski, MD
Editor-in-Chief, JBJS

The Challenges of Post-Treatment Care for Patients with Schizophrenia

The worldwide incidence of mental illness seems to be on the rise—and along with it a widespread recognition that this “epidemic” should receive at least as much attention as other health conditions. At the same time, many societies have transitioned to noninstitutionalized care for patients with severe mental health diagnoses. This parallel phenomenon has resulted in more individuals with mental and emotional challenges being cared for by their families and communities.

Orthopaedic surgeons are often asked what the prognosis is for recovery in a patient with a substantive mental health diagnosis, but only a few scholarly attempts have been made to answer that question. In the May 5, 2021 issue of JBJS, Ng et al. provide meaningful data regarding the concomitant diagnosis of schizophrenia among patients in their early 70s who experienced a hip fracture. One-year post-treatment results from this cohort study showed no differences in mortality or surgical or medical complications between patients with and matched patients without schizophrenia. These good-news findings are largely indicative of the high level of care hip fracture patients receive in the authors’ institution, which includes close collaboration among surgeons, geriatrists, physical therapists, and psychiatric clinicians.

However, the 1-year functional outcomes, as measured with the Modified Barthel Index, were worse in the cohort with schizophrenia. I think this is probably related to the difficulty of encouraging patients to participate in standardized rehabilitation processes, challenges associated with self-care, and potentially less-than-optimal social support.

We certainly need more research into determining the best peri- and post-treatment care for orthopaedic patients with severe mental health issues. Ideally, future investigations of these questions will focus on interactions between mental health professionals and surgical and rehabilitation teams. It is my hope that this study by Ng et al. will stimulate that type of research.

Click here for a downloadable Infographic summarizing this study.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Reimbursement for Revision TKA Has Not Kept Pace with Inflation

I was once told that if you don’t have any cases with complications, you either aren’t operating enough or aren’t following your patients. Although we in the orthopaedic community make every effort to minimize the occurrence of patient complications, one that remains difficult to eradicate is periprosthetic joint infection (PJI), which is a leading cause of revision total knee arthroplasty (TKA). The welfare of our patients requires successfully addressing this potentially devastating outcome, but reimbursement for these complex cases has decreased over the past decade.

In the upcoming issue of JBJS, Jella et al. offer insight on temporal trends in Medicare physician reimbursement for revision TKA. They queried the Medicare Physician Fee Schedule Look-Up Tool for pricing information corresponding to 1 and 2-stage revision TKAs and used monetary data from Medicare Administrative Contractors to calculate nationally representative means. The authors evaluated aseptic revision of 1 component, 1-stage revision (aseptic or septic), and both the first and second stages of a 2-stage septic revision.

They found that, from 2002 to 2019, there was a mild increase in the physician fee for each CPT code, with the exception of that for second-stage implantation. However, after adjusting for inflation, total Medicare reimbursements declined for both septic and aseptic revision TKAs (between 23% and 33%), with a significantly greater decline observed for septic revision.

The authors also found that Medicare spending on aseptic revision TKA nearly doubled from 2004 to 2017, while spending on septic revision TKA increased only slightly. They note that a main driver of the discrepancy between septic and aseptic revision may be the reimbursement for the second stage of the former procedure using CPT 27447 instead of a revision procedure code (27487).

We know that an increase in revision TKAs (both septic and aseptic) is expected as the number of primary TKA procedures continues to rise. If reimbursement doesn’t keep pace, it is likely to drive certain surgeons away from tackling the sometimes difficult cases, in turn, leaving our patients with fewer available resources when faced with PJI.

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

Targeted Muscle Reinnervation Helps Reduce—and Prevent—Pain in Amputees

Symptomatic neuromas have long been a problem for amputees, interfering with prosthetic comfort and causing residual pain that often requires treatment. During the last 15 to 20 years, surgeons have used targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures to improve symptoms from neuromas. In TMR, surgeons transfer a mixed or sensory nerve to a “target” transected motor nerve to prevent disorganized axonal growth. RPNI is a less complicated procedure during which the free nerve end is implanted into a denervated free muscle graft, again to decrease disorganized sprouting of axons.

Advances in amputee care at US military centers, driven largely by recent overseas conflicts, have shown anecdotally that TMR and RPNI prevent neuroma formation when used prophylactically during initial amputation, and that they also relieve pain when used as secondary treatment for existing neuromas. In the April 22, 2021 issue of The Journal, Hoyt et al. reviewed records from Walter Reed National Military Medical Center to evaluate changes in pain scores, symptom resolution, and frequency of complications when TMR and/or RPNI were utilized.

The authors analyzed 87 nerve interface interventions in 80 lower extremity amputations that had at least 6 months of follow-up. Fifty-nine of the procedures (68%) were done to treat symptomatic neuromas at a median of 6.5 years after amputation, while 28 procedures (32%) were done for primary prophylaxis. Hoyt et al. found that the sciatic nerve was most likely to develop symptomatic neuromas after amputations at or above the knee, while the tibial and peroneal nerve distributions were most commonly symptomatic after amputations distal to the knee. TMR was utilized alone in 85% of the cases, and surgeons used RPNI most frequently to prevent pain in the sural and saphenous nerves.

Overall, symptom resolution after all procedures was 92% at the final follow-up. VAS pain scores improved from 4.3 to 1.7 points in the delayed-treatment group and did not vary by amputation level. The final mean pain score in the primary-prophylaxis group was 1.0 ±1.9. There were no significant differences in pain outcomes between the primary and delayed groups, but 6 patients in the delayed cohort required revision for residual limb or phantom limb pain. In patients with transtibial amputations, failure to address an asymptomatic tibial nerve during delayed TMR resulted in an increased risk of revision surgery.

Although retrospective in nature, this study shows some encouraging early data to support the primary and secondary use of TMR/RPNI in amputee care. More research is required to determine whether these results in wounded warriors can be replicated in a civilian amputee population.

Click here for a Commentary on this study by Ann R. Schwentker, MD.

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

Better TKA Outcomes When Depression Is Addressed

In the past decade, we’ve learned through a multitude of studies that patient factors can have a substantial impact on the outcomes of orthopaedic interventions. Medical comorbidities, body habitus, and level of fitness are just a few factors we have evaluated. We also now better understand the impact of socioeconomic status and education level on access to care and the results of that care. And importantly, contemporary research is giving us a more complete picture of the relationship between a patient’s mental status and functional outcomes.

Geng et al. provide further insight into this relationship in a recent JBJS report. In a randomized controlled trial conducted at their institution in the People’s Republic of China, the authors investigated whether psychological intervention for patients with depression improved outcomes of total knee arthroplasty (TKA). Among 600 patients prospectively screened, 53 were identified with depressive disorders; 49 remained in the final analysis (24 randomized to standard TKA care and 25 randomized to perioperative psychotherapeutic interventions administered by a mental health professional). Those in the intervention group not only had a significantly higher rate of satisfaction compared with the control group, but they also showed greater improvements in functional outcome scores, range of motion, and scores on depression scales.

As Pablo Castañeda, MD emphasizes in a related Commentary on this article, “Total knee replacement cannot be seen as an isolated intervention without considering the many other factors that contribute to outcomes.” I know that mental health concerns—especially depression—can be difficult to identify during all-too-brief orthopaedic consultations with patients. But they will reap important benefits if we learn to better recognize depression, engage patients in conversations related to mental health, and team with our mental health colleagues for referrals and support. The study by Geng et al. points to a model of care with potential for wider adoption. Considering our community of highly motivated orthopaedic surgeons who are dedicated to the holistic welfare of patients, I believe it is possible to raise our skills in this area close to the level of our ability to examine a knee radiograph.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Low Adherence to Open-Fracture Antibiotic Guidelines

The prompt administration of prophylactic antibiotics is considered a critical component of open-fracture management. In 2011, the Eastern Association for the Surgery of Trauma (EAST) recommended updates to traditional antibiotic administration, including gram-positive coverage for Gustilo Type-I and Type-II fractures, the addition of gram-negative coverage for Type-III, and additional penicillin for the presence of fecal or clostridial contamination. Concerns regarding the side effects of antibiotics, along with changing patterns in bacteria resistance, have led many treating physicians to consider alternative antibiotic choices.

In a recent JBJS article, Lin et al. report on the level of adherence to open-fracture antibiotic guidelines (both traditional and EAST recommendations), analyzing data collected as part of 2 large, ongoing, multicenter trials. They also evaluated the association of Gustilo type, wound contamination, and multifracture injuries with antibiotic choice and duration.

Included were 1,234 patients from 24 medical centers in the US and Canada, all of whom received antibiotics on the day of admission. While cefazolin monotherapy was the most commonly prescribed regimen (53.6%), 54 different combinations of prophylactic antibiotics were prescribed. Lin et al. found moderate adherence to traditional antibiotic treatment guidelines for Gustilo Types-I and II fractures and low adherence for Type-III, and less-than-optimal compliance with the EAST recommendations: 31% of Gustilo Type-I and Type-II fractures received gram-negative coverage, and 54.9% of Type-III fractures did not.

The authors offer many plausible reasons for low compliance, including increased incidence of methicillin-resistant S. aureus infections, concerns regarding the nephrotoxicity of aminoglycosides, and the more frequent use of intraoperative topical antibiotics.

The median duration of antibiotic use following wound closure in this study was 2 days. The authors note that the most widely recommended duration in the literature is 3 days after wound closure, which they add, contradicts the <24 hours recommended by the EAST guidelines (for Type-III fractures, discontinuation within 72 hours post-injury or 24 hours after soft-tissue coverage).

The study provides helpful insight into the sometimes contradictory and confusing guidelines for open-fracture antibiotic prophylaxis and the variations that exist in current practice patterns. It also begs the question: is it time for a stringent new look at the guidelines and more high-quality research into which practices help ensure the best patient outcomes and the most sensible antibiotic stewardship?

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

 

Proximal Humeral Fractures: More Data on Nonunion Risk

Proximal humeral fractures tend to occur in a bimodal distribution, namely, in younger, primarily male patients and in older (>65 years of age), primarily female patients. In the latter population, such fractures are often related to low bone density, and we in the orthopaedic community now recognize the imperative to evaluate at-risk individuals through measures such as DXA scanning and laboratory assessments of bone health in order to institute appropriate monitoring and pharmacotherapy.

Regarding the treatment of these fractures, several large trials have demonstrated that, for select fracture patterns, nonsurgical care results in clinical and functional outcomes that are equal to or better than surgical care with open reduction and internal fixation or arthroplasty. The question for treating clinicians is: are there proximal humeral fracture patterns that have higher rates of complications (chiefly nonunion) following nonsurgical care?

In a retrospective study reported in JBJS, Goudie and Robinson evaluated the rate of nonunion among patients who were treated nonoperatively for a proximal humeral fracture at their regional trauma center in the UK. They also sought to develop and validate a prediction model to assess nonunion risk, measuring the effect of 19 patient demographic and radiographic variables on healing.

Overall, 231 (10.4%) of the 2,230 included patients experienced nonunion. Among those with valgus angulation of the humeral head (395 patients), the nonunion prevalence was <1%, and none of the other variables evaluated were associated with increased risk of nonunion in a multivariable analysis. However, among the 1,835 patients with neutral or varus angulation of the head, the prevalence of nonunion was 12.4%, and decreasing head-shaft angle, increasing head-shaft translation, and smoking were independently predictive of nonunion.

Important to note is the residual pain and diminished function that often accompanies nonunion. Still, the authors rightly point out that “surgery aimed solely at preventing nonunion exposes patients to the risk of other complications that are not encountered with nonoperative treatment.” But, based on these findings about fracture morphology, they conclude that “medically fit patients with translated and/or angulated fractures should be counseled about smoking cessation and considered for surgery to avoid the debilitating effects of subsequent nonunion.” Patients with these fracture characteristics deserve closer scrutiny in our efforts to provide the best treatment for proximal humeral fractures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Click here for a JBJS Clinical Summary on proximal humeral fractures.

Machine Learning Algorithm May Predict Postfracture Infection

Infection after surgery to treat a tibial shaft fracture can have devastating consequences, with significant associated costs and burdens. Although research has identified general risk factors that increase the likelihood of infection (including complexity of injury and fracture patterns and patient-related factors such as smoking and diabetes), predicting risks for individual patients remains difficult.

In a recent study in The Journal, investigators from the Machine Learning Consortium reported on an algorithm they developed to predict the risk of  infection in specific patients who receive operative treatment for a tibial shaft fracture. To develop their model, the researchers used high-quality data from the SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) and FLOW (Fluid Lavage of Open Wounds) randomized controlled trials.

The Australian researchers “trained” 5 machine learning algorithms and tested them against various performance measures to evaluate 1,822 fractures, including 170 (9%) that developed an infection. Based on predictive performance in that derivation portion of the study, 3 algorithms were validated and 1 prediction model was found to be superior. In that model, Gustilo-Anderson Type IIIA and IIIB fractures, age, AO/OTA type 42C3 fractures, crush injuries, and falls were the strongest predictors of infection.

Researchers have made their model available in an online, open-access prediction tool. Although the authors emphasize that this preliminary tool is intended for research and not for widespread clinical use, I think it has profoundly positive potential. Being able to risk-stratify a patient with a tibial shaft fracture at or near the time of admission could allow surgeons to closely monitor—and intervene sooner—in fracture cases at risk for infection, thereby possibly preventing devastating complications. This prediction tool certainly needs external validation prior to “prime-time” adoption, but when it comes to exploring artificial intelligence and machine learning in orthopaedics, the future is now.

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

Long-Term Patient Follow-up: Not Easy but Worth the Effort

Longer-term follow-up of orthopaedic patients is instrumental to research and the advancement of patient care. One simply cannot understand the impact of surgical decision-making and technique without examining the patient, assessing images, and evaluating function over time. However, in all areas of orthopaedic surgery, we struggle to get patients to return for evaluation when they feel mostly recovered. If patients are doing well in terms of pain and function, they may understandably see little or no clinical imperative to return for follow-up. This is particularly true among younger, more active patients—the primary group involved in higher-energy trauma and those who are perhaps the most resistant to follow-up visits.

Conversely, the orthopaedic research community and the journals that publish their findings have a widely embraced expectation of 1-year minimum follow-up. Agel et al. closely scrutinize this expectation/reality disconnect in a recent JBJS report. Reviewing 293 patients treated surgically for acute orthopaedic trauma injuries (mean age, 47.5 years), the authors observed a 29% rate of 1-year follow-up. Evaluating potential risk factors for patients not following up, they identified tobacco use, final appointment status (follow-up as needed vs request to return), isolated vs. multiple fractures, and distance from the trauma center as significant predictors.

While the authors ultimately concluded that a 1-year follow-up requirement “may not be feasible,” I think treating physicians can play a critical role in improving follow-up, even in trauma cases, where a physician-patient relationship may not exist prior to treatment. In addition to cementing a relationship with all our patients, we should clearly articulate that returning for evaluation will help subsequent patients with similar injuries or conditions.

In their “Author Insights” video about this study, co-authors Conor P. Kleweno, MD and Avrey A. Novak, MD cite new technologies for contacting patients for follow-up evaluations. I believe that, given convenient opportunities to do so, many patients will want to help us improve care for those who come after them.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Strengthening Our Residency Programs through Robust Research

Residency training is an essential pipeline to keeping the field of orthopaedics strong. As I tell the surgeons in my department, we should always be looking for our replacement. Who is going to carry the flag of orthopaedics after our time has passed?

Research related to education and training helps guide us. Continuing a collaboration between the American Orthopaedic Association’s (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the top abstracts from research presented at the 2019 CORD Summer Conference are now available in an article by Weistroffer and Patt on behalf of the CORD/Academics Committee.

Ten studies are featured, with a number looking at aspects of resident screening and selection. For instance, Pacana et al. evaluated use of the standardized letter of recommendation (SLOR) form; while widely adopted, it may not be a cure-all in evaluating applicants, as most applicants were “highly ranked” or “ranked to match.” Work by Secrist et al. suggests that 59 is the number of programs that medical students should target in order to obtain 12 residency interviews (with previous work showing that the average matched applicant attends 11.5 interviews). Alpha Omega Alpha status was the strongest determinant of an applicant’s interview yield. Crawford et al. surveyed residency applicants to find out which characteristics they felt were important to success in an orthopaedic residency. Hard work, compassion, and honesty made the top-10 list each year.

The importance of diversity within orthopaedics is also echoed in the included research. It is well documented that orthopaedic surgery falls far behind other specialties in this area. Among topics explored: potential differences in descriptive terms used in letters of recommendation for male and female candidates, and perceptions of pregnancy and parenthood during residency. Illustrating the importance of exposure and access to role models in orthopaedics, Samora and Cannada found that 80% of female medical students who received a scholarship to attend the Ruth Jackson Orthopaedic Society/AAOS annual meeting eventually pursued a career in orthopaedic surgery. I agree with the authors, who stated, “We must work on diversifying our field and providing opportunities for women and underrepresented minorities to consider a career in orthopaedics.”

I know we will continue to make positive change as a profession. Moreover, I am convinced that the future of orthopaedics is strong, with many with top-notch candidates ready and able to help shape our path.

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