VTE Prevention: Is Aspirin Really That Good?
OrthoBuzz occasionally receives posts from guest bloggers. In response to a three recent studies, the following commentary comes from Jeffrey B. Stambough, MD.
Throughout the last decade, we’ve experienced a boom in anticoagulation options to help prevent venous thromboembolism (VTE) associated with orthopaedic procedures. The use of aggressive anticoagulation, such as warfarin and various heparin formulations, is being questioned, largely due to concerns about bleeding risks and wound complications. Along with the newer direct oral anticoagulants such as rivaroxaban, over-the-counter aspirin (ASA) is gaining prominence as an anticoagulant due to its high efficacy, low cost, convenience for patients, favorable side-effect profile, and cardioprotective attributes. Current guidelines include the use of all these thromboprophylactic agents, but three recent studies lend credence to using aspirin as the primary VTE prophylactic agent when performing total joint arthroplasty (TJA).
In a March 20, 2019 JBJS study analyzing >31,000 TJAs performed at a single institution over 17 years, Rondon et al. found a 3-fold lower 30-day and 2-fold lower 1-year mortality rate in patients receiving ASA (81mg or 325 mg twice daily), compared to those who received non-aspirin thromboprophylaxis (mainly warfarin). No mortality differences were noted between the two ASA dosing regimens. While investigating specific causes of death, the authors discovered that the primary cause of death in the non-ASA cohort was cardiac related at all time points.
A second study, from the April 3, 2019 JBJS, looked into the effects of 3 antithrombotic agents on symptomatic VTE rates and periprosthetic infections in high-risk patients undergoing primary or revision TJA. When compared to the two more potent agents (warfarin and low-molecular-weight heparin), ASA proved more effective at reducing pulmonary embolism (PE) and VTE rates in high-risk patients, and it was also associated with lower rates of periprosthetic joint infection when compared with warfarin. Thus, it seems that even in patients deemed to be higher risk for developing VTE, ASA may be a safe, effective option.
Lastly, Runner et al. gleaned VTE prophylaxis data from >22,000 TJA cases submitted by surgeons sitting for Part 2 of ABOS between 2014 and 2016. The findings, reported in the April 2019 issue of the Journal of Arthroplasty, showed similar trends to those seen in the two previously mentioned studies: Mild (distal or superficial deep vein thrombosis [DVT]), moderate (nonfatal PE, proximal DVT) and severe (fatal PE) VTE events, as well as death, were significantly less frequent in those who received ASA compared to more aggressive agents (heparin or one of its analogs, direct oral agents, or warfarin). Also, patients who received ASA with or without mechanical prophylaxis had significantly lower complication rates (95.5% vs. 93.0%, p<0.001).
One firmly held dogma in medicine is that patients who are at higher risk for VTE should be treated with stronger anticoagulation medications. However, these 3 studies support the idea that less aggressive anticoagulation medication (specifically, low-dose aspirin) may be the more effective and safer option for most patients. In our ongoing quest to improve patient outcomes and mitigate risk around the TJA episode, we should consider using aspirin for thromboprophylaxis unless there is an explicit contraindication in a specific patient.
However, we should also keep in mind that these three studies have the common limitations of all retrospective analyses. Recent randomized trials have shown aspirin to be “noninferior” to other anticoagulants for VTE prevention, and in less than 2 years, we should have even more definitive answers to this question from the randomized, multicenter PEPPER trial, with its estimated 25,000 participants.
Jeffrey B. Stambough, MD is an orthopaedic hip and knee surgeon, an assistant professor of orthopaedic surgery at University of Arkansas for Medical Sciences, and a member of the JBJS Social Media Advisory Board.
Arthroscopy Beats PT for FAI at 8 Months
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent BMJ study, the following commentary comes from Matthew R. Schmitz, MD, FAOA.
Femoroacetabular impingement (FAI) syndrome continues to be a hot topic in the orthopaedic community. The first two decades of this century have seen huge increases in the number of hip arthroscopies performed in the US and UK,1,2 most of those to treat FAI. In the February 7, 2019 issue of BMJ, Palmer et al., reporting on behalf of the Femoroacetabular Impingement Trial (FAIT), published preliminary findings from a multicenter randomized controlled trial comparing arthroscopic hip surgery to activity modification and physiotherapy for symptomatic FAI.3
The trial randomized 222 patients with a clinical diagnosis of FAI into each cohort (110 in the physiotherapy group and 112 in the arthroscopy group). Follow-up assessments were performed by clinicians blinded to the treatment arm, and attempts were made to standardize both interventions. The participants will eventually be followed for 3 years, but this early report evaluated outcomes 8 months after randomization, with follow-up data available for >80% of patients in both groups.
Baseline characteristics with regard to demographics, radiographic findings, and clinical measurements were similar between the two groups. After adjusting for multiple potential confounders, the authors found that the mean Hip Outcomes Score Activities of Daily Living (HOS ADL) was 10 points higher in the arthroscopy group than in the physiotherapy group, exceeding the prespecified minimum clinically important difference (MCID) of 9 points. The MCID was reached in 51% of surgical patients compared to 32% in the therapy cohort. In addition, the patient acceptable symptomatic state (PASS)—defined as a HOS ADL ≥87 points—was achieved in 48% of surgical patients and only 19% of therapy patients. Relative to the physiotherapy group, the arthroscopic group also had better hip flexion and superior results in a variety of commonly used hip patient-reported outcomes scores.
The 8-month data from this study show that there is a real improvement in patient function and reported outcomes from arthroscopic management for FAI. It will be important, however, to follow these patients for the entire 3 years of the FAIT study to show whether these improvements persist. It should also be emphasized that only half of the patients treated with surgical management achieved MCID at the 8-month point. That finding supports what I tell patients in my young-adult hip-preservation clinics, which seems relevant as baseball season starts: There are rarely any home runs in arthroscopic hip surgery. There are mainly singles and doubles that we hope to stretch into doubles and triples. Still, it appears that even those base hits with arthroscopic surgery are better than the physiotherapy alternative—at least in the early innings of the game.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
References
- Maradit Kremers H, Schilz SR, Van Houten HK et al. Trends in Utilization and Outcomes of Hip Arthrocopy in the United States Between 2005 and 2013. J Arthroplasty 2017; 32:750-5.
- Palmer AJ, Malak TT, Broomfield J, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2018. BMJ Open Sport Exerc Med 2016;2:e000082
- Palmer AJ, Gupta VA, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicenter randomized controlled trial. BMJ 2019; 364:l185
Letting Go of the Script
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New England Journal of Medicine Perspective, the following commentary comes from Adam Bitterman, DO.
The physician-patient relationship is highly regarded and has withstood the test of time. Unfortunately, today it appears to be under significant stress. While it is still possible to maintain a meaningful and professional doctor-patient connection, the balance between arriving at a correct diagnosis, moving down your patient list, and truly caring for each individual patient is difficult to find. The advent of electronic medical records (and their attendant task lists and button clicking) and satisfaction scores have not made maintaining meaningful patient relationships any easier.
In her February 7, 2019 Perspective piece for The New England Journal of Medicine, cardiologist Dr. Lisa Rosenbaum describes her encounters with the medical system as a patient after sustaining a Jones fracture. As she highlights her experience from the initial presentation in the emergency department to the follow-up examination with an orthopedic surgeon, she describes the repeated sensation of being a diagnosis treated by an algorithm rather than an individual with an ailment receiving care.
She also highlights an anecdote about another patient’s family pleading with a staff physician to “get off your script” and focus on treating the unique patient. Invoking the legacy of Sir Robert Jones, the orthopaedist after whom the foot fracture is named, Dr. Rosenbaum observes that “medicine teeters atop an edifice of workarounds,” as physicians try to play by the rules while taking good care of patients.
Standardization and treatment protocols have a useful role in many instances, but we physicians must remember that behind every complaint is a patient, an individual with personal connections to friends and family. It is easy to get caught up in the standardized protocols that reside within electronic medical records, but it takes only a moment to disconnect yourself from the screen and keyboard and provide the creative connection that patients desire. (A study in the upcoming February 20, 2019 JBJS addresses this topic.)
Although you may be encountering your seventh patient of the day with a Jones fracture, for each of those people, their foot is all that matters. It is our job—a decidedly difficult one—to provide the unique and sometimes creative treatment plan to all our patients, while somehow maintaining a top-tier standard of care that is reproducible for all.
Adam Bitterman, DO is a fellowship-trained foot and ankle surgeon practicing at Northwell Health in Huntington, NY. He is also a member of the JBJS Social Media Advisory Board.
PE Prevention—There’s an App for That
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD in response to a recent study in the Journal of Orthopaedic Trauma.
Pulmonary embolism (PE) is a potentially life-threatening complication among many orthopaedic trauma patients. PE can be a silent killer, with only about 30% of fatal PEs being detected before death. Chemical prophylaxis with “blood thinners” such as injectable enoxaparin is effective in mitigating the risk of PE, but in the poly-traumatized patient, its application is often contraindicated. In an effort to develop a more effective approach to PE prevention in the trauma population, Starr et al. built a tool to estimate the risk of PE early and effectively, and then developed a multidisciplinary protocol for deep vein thrombosis (DVT) prophylaxis. They present their preliminary experience with the risk-assessment tool and the new protocol in the February 2019 issue of the Journal of Orthopaedic Trauma.
The smart-phone app (ParkLandOrtho) to risk-stratify trauma patients in the ED is based on 7 easily captured variables that the authors’ prior work identified as statistically significant predictors for developing a PE. Patients who are identified as “high risk” are aggressively started on enoxaparin, with the first dose ideally given prior to ED discharge. If contraindications for chemical prophylaxis are present, enoxaparin is withheld for up to 24 hours after admission. After 24 hours, if the patient is still unable to receive enoxaparin, a removable inferior vena cava (IVC) filter is placed.
The authors performed a retrospective review of PE incidence among 368 consecutive orthopaedic trauma patients admitted to their hospital after this new protocol was implemented and compared it to PE incidence among a historic cohort of 420 similar consecutive patients admitted during the year prior to the protocol. The two groups were similar in age and injury severity. In the control group, 51 patients were retrospectively classified as high risk, and 9 patients (2.1%) developed symptomatic PEs, one of which was fatal. In the group managed under the new protocol, 40 patients were identified as high risk, and only 1 patient (0.27%) developed a nonfatal PE. The difference in incidence of PE between the two groups was statistically significant (P = 0.02).
This paper highlights two significant achievements in my opinion. First, I was excited to see the success of a smart-phone app to facilitate rapid risk assessment. This was a significant key to the success of the multidisciplinary PE protocol, which depends on buy-in and compliance. Second, this thoughtful, decisive, and team-based protocol for DVT/PE prophylaxis in an orthopaedic trauma setting seems to be making a meaningful impact on patient outcomes.
The authors report that they are currently designing a multicenter trial to prospectively validate their protocol. I eagerly await this and hope that their next step includes a ParklandOrtho app release for Android devices, as it is only available now for iPhone and Samsung users.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Musculoskeletal Infections: Oral Antibiotics Not Inferior to IV
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New England Journal of Medicine study, the following commentary comes from Daniel Leas, MD and Joseph R. Hsu, MD.
Deep infections continue to be one of the most resource-intensive problems that orthopaedic surgeons face. Long-standing dogma has favored 6 or more weeks of intravenous (IV) antibiotics, resulting in increased healthcare costs during both the inpatient and outpatient treatment periods.
To explore the possibility of utilizing targeted oral antibiotics as an alternative, effective treatment for musculoskeletal infections, the OVIVA (Oral versus Intravenous Antibiotics) multicenter research collaboration conducted a prospective, randomized controlled trial. A total of 1,054 patients with deep musculoskeletal infections were randomized to oral or IV arms for 6 weeks of antibiotic treatment and followed for 1 year to determine treatment efficacy. The primary end point was treatment failure within 1 year, defined as the presence of predefined clinical symptoms of deep infection, microbiologic evidence of continued infection, or histologic presence of microorganisms or inflammatory tissue. Secondary outcomes included catheter-associated complications, discontinuation of therapy, and Clostridium difficile diarrhea.
Of the 1,054 patients enrolled, 909 patients were included in the final analysis. Treatment failure occurred in 14.6% of patients treated with IV antibiotics and 13.2% of patients in the oral-therapy group. This -1.4% difference indicated noninferiority based on the predetermined 7.5% noninferiority margin. Secondary outcomes between the groups differed only in catheter-related complications being more common in the IV group (9.4% vs 1.0% in the oral group).
These findings and conclusions should challenge us to re-evaluate the basis for extended IV antibiotics to treat complex musculoskeletal infections, and to consider a greater role for oral antibiotics for such infections. Further study of this question focused on patients with retained hardware is warranted.
Daniel P. Leas, MD is a PGY-5 orthopaedic resident at Carolinas Medical Center.
Joseph R. Hsu, MD is a Professor of Orthopaedic Trauma and Vice Chair of Quality at the Atrium Health Musculoskeletal Institute.
Orthopaedic Surgeons Must Educate Communities About Youth Sports Injuries
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Carl Nunziato, MD and Anthony Johnson, MD in response to a TV news segment on WLWT in Cincinnati.
While viewing the WLWT segment on youth sports injury, we were encouraged that the reporter sought out a local orthopedic surgeon to comment on the risks associated with single-sport specialization. As orthopaedic surgeons, our opinions are a trusted voice in our communities, and we need to educate athletes, coaches, and parents alike of the dangers of such specialization. We commend Dr. Timothy Kremchek for his involvement in his local community and have felt the frustration he expressed regarding the rising sport-injury rates among adolescents.
However, we caution providers against characterizing single-sport specialization as “child abuse,” as Dr. Kremchek did in this segment. This extreme language, even if used to emphasize the potentially serious nature of some sport injuries, is counterproductive. Instead, we encourage all musculoskeletal clinicians to focus on educating the public on how to reduce risk in adolescent athletes, rather than shaming or blaming.
We’ve helped many patients—both minors and adults—as they struggled to rehab from injuries, only to realize that returning to the same level of competition may not be possible. In such cases, many patients and/or their parents ask the same guilt-ridden questions as the mother of the young basketball player in the news segment: “Did I make a mistake? Did I push too hard?”
It is true that youthful participation in a single sport year-round has been shown to result in increased injury rates, burnout, and possibly even limitations in peak performance in the chosen sport due to delayed development of other muscle groups and fine motor skills. We also cannot deny the risks and costs associated with the increase in operations on young athletes. It’s key to remember, however, the principal concept of patient autonomy. As the young patient in the story reminds us, these kids often truly love their sport – and many would choose to continue participating even if they knew the risk and seriousness of eventual injury.
Instead of using sensational phrases like “child abuse,” which may frighten families or stir up feelings of guilt, we should provide resources for coaches, parents, physicians, and athletes aimed at encouraging healthy participation and minimization of one-sport injuries. One example is the AAOS/AOSSM OneSport initiative. Educating patients and their families requires significant time and effort on the part of the orthopaedic surgeon, but it is likely to result in a more positive interaction with the patient and parents. And these interactions may help emphasize the long-term lifestyle behaviors that we are hoping to cultivate among these vulnerable populations.
Carl A. Nunziato, MD is a resident in orthopaedic surgery at Dell Medical School in Austin, Texas. Anthony Johnson, MD is the orthopaedic surgery residency program director in the Department of Surgery and Perioperative Care at Dell Medical School.
Less Pain, More Gain with Just One Screw
Image courtesy of AO Surgery Reference
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD in response to a recent study in the Journal of Orthopaedic Trauma.
Low-energy sacral fractures in the geriatric population typically heal over time without operative intervention. Nonoperative treatment usually involves analgesics and progressive rehabilitation. Unfortunately, given the frailty and low physiologic reserves of many in this patient population, these fractures can still take a significant toll. Fracture pain may last for weeks to months; deconditioning occurs secondary to poor mobilization; and many patients are discharged to skilled nursing facilities rather than returning directly home.
Given this associated morbidity, Walker et al.1 asked whether percutaneous transiliac-transsacral screw fixation could offer some benefit in the treatment of sacral fragility fractures. The authors present a retrospective review of 41 elderly patients who were admitted with sacral fragility fractures. All patients first received a trial of nonoperative management, which included analgesia and physical therapy-guided mobilization. If patients were unable to appropriately ambulate secondary to pain, they were offered surgery. Sixteen patients elected surgery, which consisted of transiliac-transsacral screw fixation of the posterior pelvic ring.
After surgery, the operative group reported greater reductions in pain than the nonoperative cohort, and they were more likely to be discharged directly home from the hospital (75% versus 20%). Furthermore, at the time of discharge, 100% of the surgical patients were able to ambulate with physical therapy, compared to only 72% of the nonoperative group. No surgical complications occurred, and the average total surgical time was only 34 minutes.
Sacral fragility fractures can result in significant pain and disability in an already frail population. While these fractures are typically managed conservatively, this study suggests that some patients may benefit from surgical intervention. Percutaneous transiliac-transsacral screw fixation is a relatively low-risk procedure (at least in the normomorphic sacrum). And if a single screw can reduce pain, improve function, and more quickly return geriatric patients to their baseline level of independence, then the risk-benefit calculus would favor surgery, unless specific contraindications are present.
While this study is not powerful enough to rewrite treatment protocols, it does give credence to considering surgical fixation for sacral fragility fractures in those who still struggle after a trial of conservative management, and it makes a strong argument for further investigation.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Reference
- Walker, J. Brock, et al. “Percutaneous Transiliac–Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home.” Journal of orthopaedic trauma 32.9 (2018): 452-456.
German Knee OA Guidelines Mirror Findings in JBJS Reviews Article
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Prof. Joerg Jerosch, in response to a recent article in JBJS Reviews.
I congratulate Vannabouathong et al. for the well-performed and relevant systematic review. In Germany, the Association of Scientific Medical Societies (AWMF) just published a guideline on the medical treatment of knee osteoarthritis (see: https://www.awmf.org/uploads/tx_szleitlinien/033-004l_S2k_Gonarthrose_2018-01_1.pdf), which comes to very similar conclusions as those presented in this systematic review.
The new German guideline suggests a four-stage algorithm starting with topical NSAIDs and escalating to oral NSAIDs (according to individual risks), then followed either by glucosamine, hyaluronic acid (HA), or corticosteroids, and ends finally with opioids. It was very useful that Vannabouathong et al. used the AAOS description for clinical significance, and it was elegant of them to include the effect of intra-articular placebo in their analysis of intra-articular treatments. This review compares treatment-group differences (not within-patient improvements) and considers that the placebo effect in osteoarthritis trials is typically large, particularly in the case of intra-articular injections. Consequently, the measured effect size would underestimate the clinical benefits for patients1, 2. It is valuable that this systematic review calculated the intra-articular placebo versus the oral placebo effect and added the resulting difference of 0.29 standard deviation (SD) units to the respective effect sizes of the intra-articular treatments.
This review concludes that the intra-articular injection of HA has the most concise effect estimate and exceeds the defined threshold of clinical importance of 0.5 SD units. Thus the clinical usefulness of HA is boosted from “possibly clinically important” to “clinically important” according to the AAOS definitions. This review also investigates HA formulations in terms of different molecular weights. It illustrates clearly the effect sizes of high-molecular-weight HA formulations between 1,500 kDa and 6,000 kDa, as well as those above 6,000 kDa.
One point requiring further discussion is that many patients have contraindications to NSAIDs due to comorbidities or comedications. Our new German guideline points out that NSAIDs are contraindicated for elderly patients (>60 years old) and those with existing ulcers, GI bleeding, or infections with H. pylori. Additional contraindicated factors are comedications such as corticosteroids, anticoagulants, or aspirin. In addition, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) reasons that oral NSAIDs have a moderate effect on pain relief, but they are associated with a 3- to 5-fold increase in the risk of upper GI complications, including peptic ulcer perforation, obstruction, and bleeding3.
Another analysis from the Coxib and Traditional NSAID Trialists (CNT) Collaboration shows that 2 to 4 out of 1,000 patients face GI complications after the daily intake of 150 mg of diclofenac. The same applies for 6 to 16 out of 1,000 patients taking 1,000 mg of ibuprofen per day4. An announcement of the Medicines Commission of the German Medical Profession also mentions high relative risks for GI complications associated with NSAIDs. The German guideline recommends intra-articular HA injections especially for individuals at risk for adverse NSAID side effects and for those for whom NSAIDs are not sufficiently effective.
The German guideline also discusses potentially beneficial effects of combining corticosteroids with HA. This should be a topic for a future systematic review.
Prof Joerg Jerosch is a professor of orthopaedic surgery at Johanna-Etienne Hospital in Neuss, Germany.
References
1. Bannuru RR et al., Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis e meta-analysis, Osteoarthritis Cartilage. 2011 Jun;19(6):611-9. doi: 10.1016/j.joca.2010.09.014.
2. Bannuru RR et al., Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis, Ann Intern Med. 2015 Jan 6;162(1):46-54. doi: 10.7326/M14-1231
3. Bruyere O et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting. Semin Arthritis Rheum, 2016. 45(4 Suppl): p. S3-11
4. Bhala N et al., Coxib and traditional NSAID Trialists’ (CNT) Collaboration, Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013; 382(9894): 769-779
Immobilization after Fixation of Distal Radial Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in JBJS.
Postoperative immobilization after internal fixation of fractures is common practice. However, immobilization after locked volar plate fixation of distal radial fractures may actually thwart our patients’ rehabilitation—at least in the short term. So suggest the findings from Watson et al. in the July 5, 2018 issue of JBJS.
The authors randomized 133 patients who underwent locked volar plate fixation of distal radial fractures to 1, 3, or 6 weeks of postoperative immobilization. All patients were placed into volar splints postoperatively. After 1 week, splints were removed entirely or converted to short-arm circumferential casts based on the patient’s allocation. All patients started physical therapy within 3 days of definitive splint or cast removal.
Outcomes were evaluated at 6, 12, and 26 weeks and included patient-reported measures (PRWE, VAS pain scores, and DASH), active wrist range of motion, and postoperative complications. Six weeks following surgery, the results favored 1 or 3 weeks of immobilization over 6 weeks of casting in terms of improved patient-reported outcomes and objective wrist range of motion. However, those between-group differences disappeared at 12 and 26 weeks of follow-up. No significant differences were found in complication rates between the 3 groups.
For me, the primary message of this article is that early mobilization after distal radial fracture fixation offers improved short-term outcomes with little or no risk of adverse effects. For most patients, a major goal of fracture treatment is to restore normal function as quickly as possible. With early mobilization, patients reported less pain and less disability, and they demonstrated greater range of motion at 6 weeks.
However, the quick restoration of function must be done safely and without complications. In this cohort, 6 patients lost fracture reduction—5 in the 1-week immobilization group and 1 in the 6-week group. While that difference was not statistically significant, the study was not sufficiently powered to detect that difference. A quick power analysis, assuming an anticipated 11% loss-of-reduction rate as seen in the 1-week group and a 2% rate as seen in the 6-week group, estimates that 234 patients would be needed to confidently avoid a type II error when analyzing loss of reduction.
Translating findings like these into practice constitutes the art of medicine. It is probably safe, and perhaps even beneficial, to allow early mobilization of distal radial fractures treated with volar locking plates. However, there is probably a subset of patients who are at risk for losing reduction, and therefore it may be prudent to have a low threshold for keeping certain patients casted for a longer duration. The orthopaedist who extends cast immobilization beyond 3 weeks can take comfort in the findings that reported outcomes and range of motion in the 6-week-immobilization group quickly caught up with the results of the early-mobilization cohorts by 12 weeks after surgery.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Guest Post—Peer Reviewers: Who Are They and Do They Agree?
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher Dy, MD, MPH, in response to a recent study in PNAS.
I am a young surgeon, but I have been submitting papers and grants for peer review for 11 years, since I was a third-year med student. I have tasted the bitterness of rejection more times than I would like to admit, several times at the hands of JBJS. But I will say, without a doubt, that the peer-review process has made my work better.
Acknowledging that our work is far from perfect at the point of submission, most of us have turned the question around: How good and reliable is the peer-review process? Several related questions arise quickly: Who are the “peers” doing the reviewing? We put weeks and months into writing a paper or submitting a grant, which then vanishes into the ether of a review process. How do we know that we are getting a “fair shake” from reviewers, who, being human, carry their own biases and have their own limitations and knowledge gaps—in addition to their expertise? And do the reviewers even agree with each other?
Many authors can answer “no” to that last question, as they have likely encountered harmony from Reviewers 1 & 3 but scathing dissent from Reviewer 2. Agreement among reviews was the question examined by Pier et al. in their recent PNAS study. Replicating what many of us consider the “highest stakes” process in scientific research, NIH peer review, the authors convened four mock study sections, each with 8 to12 expert reviewers. These groups conducted reviews for 25 R01 grant proposals in oncology that had already received National Cancer Institute funding. The R01 is the most coveted of all NIH grants; only a handful of orthopaedic surgeons have active R01 grants.
Pier et al. then evaluated the critiques provided by the reviewers assigned to each proposal, finding no agreement among reviewer assessments of the overall rating, strengths, and weaknesses of each application. The authors also analyzed how well these mock reviews paired to the original NIH reviews. The mock reviewers (all of whom are R01-funded oncology researchers) “rated unfunded applications just as positively as funded applications.” In their abstract, Pier et al. conclude that “it appeared that the outcome of the [mock] grant review depended more on the reviewer to whom the grant was assigned than the research proposal in the grant.”
From my perspective as a taxpayer, this is head-scratching. But I will leave it to the lay media to explore that point of view, as the New York Times did recently. As a young clinician-scientist, these results are a bit intimidating. But these findings also provide empirical data corroborating what I have heard at every grant-funding workshop I’ve attended—your job as a grant applicant is to communicate clearly and concisely so that intelligent people can understand the impact and validity of your proposed work, regardless of their exact area of expertise. With each rejection I get, either from a journal or a funding agency, I now think about how I could have communicated my message more crisply.
Sure, luck is part of the process. Who you get as a reviewer clearly has some influence on your success. But to paraphrase an axiom I’ve heard many times: The harder I work, the more luck I seem to have.
Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.
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