How Much Radiation Does a Surgeon’s Brain Receive during Femoral Nailing?
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent article in JBJS.
Surgeon exposure to ionizing radiation during C-arm fluoroscopy is common during many orthopaedic procedures, including fracture reduction and fixation-implant positioning. With increased exposure, concern about potential health risks to staff also increases.
A new study in the November 18, 2020 issue of The Journal of Bone & Joint Surgery estimates how much radiation a surgeon’s brain is exposed to while performing short cephalomedullary (SC) nailing over a 40-year career. Ramoutar et al. used two cadaveric specimens (one representing the patient and one head-and-neck specimen representing the surgeon) during a simulated fluoroscopic-guided femoral-nailing procedure.
The dose of radiation to the brain was measured with sensors implanted in the cadaver brain and placed superficially on the skull. Measurements were made with the surgeon specimen set up with different configurations of personal protective equipment (PPE) to test their effectiveness at shielding the brain from radiation.
Ramoutar et al. calculated that the overall extrapolated lifetime dose over 40 working years for surgeons performing 16 SC nailing cases per year without PPE was 2,146 µGy, which is comparable to the radiation exposure during a 1-way flight from London to New York. The authors also found that the use of a thyroid shield was very effective in reducing the radiation exposure to the brain, although the use of additional PPE (e.g., leaded glasses and lead cap) did not add any significant reduction in brain exposure to radiation.
In addition to concluding that the lifetime brain dose of radiation from SC nailing is low, the authors say the findings should encourage surgeons performing this procedure to use thyroid shields. This study also provides a repeatable methodology for future studies investigating brain-radiation doses during other common orthopaedic procedures.
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.
Seeking Molecular Signatures of Ectopic Bone Formation
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to an article in the November 4, 2020 JBJS.
Among military personnel who sustain blast-related injuries, physicians have observed a dramatic increase in the incidence of heterotopic ossification (HO), a pathology in which bone grows abnormally within soft tissues. This condition is frequently observed in association with burns and nonmilitary orthopaedic trauma, and combat-related HO is now occurring at an exceptionally high frequency of approximately 60%.
HO can range from an asymptomatic, incidental finding to a debilitating condition causing chronic pain and impaired movement. Although symptomatic HO is usually treated with surgical excision, identifying HO early in its development could go a long way toward improving quality of life for those with combat injuries.
Previous studies have suggested that certain microRNAs (miRNAs) play an important role in the formation of post-traumatic HO. A group of US researchers recently hypothesized that specific miRNA “signatures” might be present in the tissues of military personnel soon after a blast injury.
The authors collected 10 tissue samples from injured servicemembers during the surgical debridement of their wounds, about 8 days after the initial injuries occurred. The miRNA profiling of the samples, performed using a real-time polymerase chain reaction array, revealed that the tissues from patients who developed HO had upregulated levels of 6 miRNAs previously thought to take part in various bone-formation processes. Moreover, when some of those miRNAs were introduced into cultures of mesenchymal progenitor cells, the researchers found that 2 specific miRNAs (miR-1 and miR-206) were the most robust osteogenic “enhancers.” Interestingly, those same 2 miRNAs were found to target the downstream transcription factor SOX9, a deficiency of which can lead to a skeletal malformation syndrome.
These findings show that there are indeed early molecular signatures in the tissues of patients whose injuries progress to HO. While these novel insights into the molecular mechanisms underlying the development of HO may open doors to new therapeutic possibilities, Takamitsu Maruyama, PhD, in a commentary on the findings, cautions that modulating miR-1 and miR-206 “could affect not only HO formation but also the bone-healing process.”
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.
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.
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.
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.
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:
- Mentors: We want to support the applicants who have worked with us.
- 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:
- Agency (e.g., “assertive,” “confident,” “outspoken”)
- Communal (e.g., “careful,” “warm,” “considerate”)
- Grindstone (e.g., “dedicated,” “hardworking,” “persistent”)
- Ability (e.g., “adept,” “intelligent,” “proficient”)
- 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.
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.
Less Drinking/Smoking Associated with Fewer Hip Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Shahriar Rahman, MS in response to a recent study in JAMA Internal Medicine.
Hip fractures are an important cause of morbidity and mortality among the elderly population worldwide. However, age-adjusted hip fracture incidence has decreased in the US over the last 2 decades. While many attribute the decline to improved osteoporosis treatment, the definitive cause remains unknown. A population-based cohort study of participants in the Framingham Heart Study prospectively followed a cohort of >10,000 patients for the first hip fracture between 1970 and 2010.
The age-adjusted incidence of hip fracture decreased by 4.4% per year during this study period. That decrease in hip fracture incidence was coincident with a decrease over those same 4 decades in rates of smoking (from 38% in 1970 to 15% by 2010) and heavy drinking (from 7% to 4.5%), with subjects born more recently having a lower incidence of hip fracture for a given age. Meanwhile, during the study period, the prevalence of other hip-fracture risk factors–such as being underweight, being obese, and experiencing early menopause–remained stable.
This study’s findings should be interpreted in light of 2 major limitations. First of all, there was a lack of contemporaneous bone mineral density data across the study period; secondly, all the study subjects were white. Nevertheless, these findings should encourage physicians to continue carefully managing patients who have osteoporosis and at the same time caution them against smoking and heavy drinking.
Shahriar Rahman, MS is an assistant professor of orthopaedics and traumatology at the Dhaka Medical College and Hospital in Bangladesh and a member of the JBJS Social Media Advisory Board.
Guidelines for Resuming Elective Orthopaedic Surgery
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Adam Bitterman, DO in response to 2 recent articles in the July 15, 2020 issue of The Journal of Bone & Joint Surgery.
The United States continues to struggle in the grip of the global COVID-19 pandemic. Certain regions within the US are experiencing a sharply increased COVID-19 case volume, while other locales have stabilized their disease burden. But overall, the country’s healthcare system and economy remain under stress.
Healthcare systems in regions that don’t have high COVID-19 burdens have begun to provide their full list of services, of which elective orthopaedic surgery is one. However, amid concern about a “second wave” of the pandemic, the reemergence of elective orthopedic surgery must be made–and monitored–in the context of public health. Now more than ever, surgeons and their patients must consider how individual patient-centered decisions might play out in the public domain.
As Anoushiravani and colleagues point out, the return of elective orthopedic surgery should be based in large part on the COVID-19 burden in any given geographic location. Local jurisdictions must regulate the return to “normalcy” according to measurements that gauge activity of the virus, such as the number of new diagnoses and hospitalizations and the percent occupancy of ICU beds. In another JBJS article on this topic, Parvizi et al. emphasize that local hospitals and health systems need to weigh resumption of elective orthopaedic procedures also against staffing capability and available supplies of PPE and ventilators. The sensible recommendations from both sets of authors emphasize the importance of ascertaining local disease patterns in order to provide appropriate and safe care for all patients.
The new “normal” in healthcare is a moving target that requires fluidity and flexibility to make frequent reassessments. The economic disruption caused by the pandemic may take years to resolve, and economics is another factor in these resuming-surgery equations. As members of the healthcare team, it is imperative that we focus on the well-being of our patients, surgical team and staff, and our local community. We all must be vigilant for signs of resurgence of the disease. And, please, wear a mask whenever you are out in public and social distancing is not feasible.
Adam Bitterman, DO is a foot and ankle specialist, an assistant professor of orthopaedic surgery at Zucker School of Medicine at Hofstra/Northwell, and a member of the JBJS Social Media Advisory Board.
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