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The Need for Preop Psych Evals in Orthopaedic Surgery

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

In orthopaedic surgery, pre-existing psychiatric conditions in patients can have a detrimental effect on outcomes. Previous studies have shown poor improvement in postoperative self-reported pain scores among patients with psychosomatic conditions or mood disorders. Robust published evidence also suggests that psychiatric conditions can lead to complications in the treatment course, including an increased length of hospital stay and higher total systemwide costs. However, despite compelling evidence in the literature, orthopaedic surgeons—especially those early in their career—lack protocols to evaluate a patient’s current and past psychiatric history and symptom severity.

A recent “What’s Important” article in The Journal of Bone & Joint Surgery emphasizes the need for such an assessment tool. In the article, Albert T. Anastasio, MD, a resident in orthopaedic surgery at Duke University Medical Center, cites the example of bariatric surgery, where protocols have long existed for preoperative patient assessments for a history of alcohol and drug abuse. He argues convincingly that the development and use of such tools should be extended to orthopaedic procedures. For example, Dr. Anastasio questions the wisdom of a hypothetical elective spine surgery in a patient with an unaddressed psychosomatic disorder and borderline pathology on advanced imaging.

At the same time, Dr. Anastasio is quick to highlight the challenges of developing such a tool, mainly because of the subjective nature of psychiatric symptoms. But he cites existing tools that attempt to objectively evaluate psychiatric symptoms, such as the Patient Health Questionnaire-9, which is used to quantify the severity of major depressive disorder. Dr. Anastasio also cautions that any such metric should not serve as a “definitive cutoff” for surgery.

Underlying Dr. Anastasio’s call for psychiatric risk-assessment protocols is the importance of developing and enhancing collaboration between orthopaedics and psychiatry, two disciplines that he says are often “considered very far removed from each other.”

Impact Science is a team of 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. Impact Science aims to democratize science by making research-backed content accessible to the world.

JBJS Extends Deadline for International Journal Club Grants

For the first time, JBJS is expanding its Robert Bucholz Resident Journal Club Grant Program to orthopaedic residency programs beyond North America.

The deadline for international applicants has been extended until 31 October 2020.

Grants of US$1,500 will be awarded to support selected Journal Club programs for the coming academic year. Funds can be used for subscriptions to orthopaedic journals and resources, travel grants for guest speakers, and costs associated with the monthly journal club meetings.

To apply, click here, download and fill out the form, and return it to journalclub@jbjs.org by 31 October 2020.

What I Learned at the ASSH 2020 Virtual Annual Meeting

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.

The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:

  • A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
  • The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
  • While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.

Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.

  • Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
  • The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
  • Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
  • Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)

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.

“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.

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.

 

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

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. 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. 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!

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!

Pledge from JBJS Regarding Race-Based Inequalities

The JBJS Board of Trustees published a statement today that addresses the global COVID pandemic and the worldwide demonstrations against systematic racism. As an organization, JBJS has pledged to take the following actions to promote racial equality in health care and in other aspects of human affairs that we influence:

  • In addition to the >100 articles already published in JBJS that explore health care disparities, The Journal will now prioritize manuscripts that delineate solutions to these widespread inequities.
  • JBJS will continue to support initiatives that increase minority representation in orthopaedic surgery programs throughout the US—including minority members of academic faculties. We will also publish data on the results of those efforts.
  • JBJS will look inward to promote greater diversity within our own organization.

We hope the readers of JBJS and OrthoBuzz are also taking action in their homes, workplaces, and communities to ensure that all people are treated fairly and equally.

High-Level Clinical Research in Developing Countries? Yes!

Generally speaking, orthopaedic surgeons in low-resourced environments deliver the best care for their patients with skill, creativity, and passion. These surgeons are accustomed to scrambling for implants and other tools and to working around limited access to operating theaters and anesthesia services. Their everyday struggles usually leave little energy or time to even think about clinical research.

However, in the May 20, 2020 issue of The Journal, Haonga and colleagues prove that, with a “little help from their friends,” it is possible to conduct Level I research while treating patients in a resource-limited setting. They enrolled and followed 221 patients with open tibial fractures (mostly males in their 30s injured in a road-traffic collision) and randomized them to treatment with either uniplanar external fixation or intramedullary (IM) nailing. The nails were supplied by SIGN Fracture Care International, a not-for-profit humanitarian organization that provides specially designed IM nails that can be used without image intensification to hospitals in developing countries around the world. (See related OrthoBuzz post.)

The research was done in Dar es Salaam, Tanzania, in collaboration with trauma surgeons and epidemiologists from the University of California San Francisco, which has a long-standing relationship with Tanzania’s Muhimbili National Hospital. At the 1-year follow-up, there were no significant between-group differences in primary-outcome events—death or reoperation due to deep infection, nonunion, or malalignment. IM nailing was associated with a lower risk of coronal or sagittal malalignment, and quality-of-life (QoL) scores favored IM nailing at 6 weeks, but QoL differences dissipated by 1 year.

Just as important as the clinical findings, these investigators proved that it is possible to do high-level research in centers with high patient volume and limited resources. Future patients will benefit because the clinicians now have better information to share regarding expectations for functional recovery and risk of infection. Physicians and other healthcare professionals benefit because data like this help improve their analytical skills and become more discerning appraisers of the published literature. With strong internal physician leadership and a little outside support, Haonga et al. have convinced us that prospective—and even randomized—research is possible in these special places.

Finally, SIGN deserves our support as a true champion of orthopaedic surgeons working in under-resourced environments. In addition to providing education and implants, SIGN surgeons are required to report their cases through the SIGN Surgical Database—which encourages the research mindset and helps SIGN surgeons improve tools and techniques for better patient outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief