Archive | Need to Know RSS for this section

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.

Reducing Local Recurrence of Adamantinomas

The international multicenter study by Schutgens et al. in the October 7, 2020 issue of JBJS reports findings from an analysis of >300 cases of patients diagnosed with either classic adamantinomas (ADs) or osteofibrous dysplasia-like adamantinomas (OFD-ADs) who were followed for 7 to >10 years. The mean age at diagnosis was 17 years. The authors conclude that OFD-AD and AD are “parts of a disease spectrum but should be regarded as different entities.” Their findings, they say, also “support reclassification of OFD-AD into the intermediate locally aggressive [but non-metastatic] category” of bone tumors.

Perhaps the most clinically interesting findings in this study are related to local recurrence, which the authors describe as a “multifactorial” phenomenon in both tumor types. They found local recurrence in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD, which is a malignant disease with metastatic potential.

The authors found that the unadjusted cumulative incidence of local recurrence was higher if a pathological fracture was reported and if resection margins were contaminated. So, to reduce the risk of local recurrence in both tumor types, Schutgens et al. suggest “preventing pathological fracture after diagnosis and achieving uncontaminated margins with resection.”  The uncontaminated resection should include the periosteum of the involved bone at the time of surgery.

Cannabis Users Should Disclose Prior to Surgery

Although many patients believe marijuana is an effective agent to treat chronic and nerve pain, the effect of cannabis on acute musculoskeletal pain has been questioned. In an OrthoBuzz post from 2019, we reported findings published in JBJS indicating that, compared with “never users,” patients who reported using marijuana during recovery from a traumatic musculoskeletal injury experienced increases in both total prescribed opioids and duration of opioid use.

At the 2020 annual meeting of the American Society of Anesthesiologists, researchers reported parallel findings. Among 118 patients who underwent open reduction and internal fixation to repair a tibial fracture, 25% reported using cannabis prior to surgery. When researchers compared the patients who had used cannabis with those who had not, they found the following perioperative and postoperative results among the users:

  • A higher intraoperative requirement for inhalation anesthetic
  • Higher reported pain scores while in the postacute care unit after surgery
  • Higher in-hospital postoperative opioid consumption

In a press release about this study, lead author Ian Holmen, MD is quoted as saying, “…it is important for patients to tell their physician anesthesiologist if they have used cannabis products prior to surgery to ensure they receive the best anesthesia and pain control possible.”

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

Cost-Effectiveness of PRP for Knee OA Questioned

The cost-effectiveness analysis of platelet-rich plasma (PRP) for knee osteoarthritis by Rajan et al. in the September 16, 2020 issue of JBJS is accompanied by 105 references. That’s just one indication of the level of interest in this anti-inflammatory and pro-angiogenic orthobiologic. Current literature suggests that PRP is safe, but its clinical efficacy in musculoskeletal conditions has been hotly debated in the orthopaedic community.

Rajan et al. applied Markov decision analysis to a clinical scenario in which a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis (OA) undergoes either a series of 3 PRP injections and a 1-year delay to total knee arthroplasty (TKA), or TKA from the outset. Their primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs). In Markov analyses, if one treatment costs less and produces more QALYs than a comparative treatment, it is considered to be the “dominant” approach.

The authors found that, from a health-care payer perspective, PRP (at an estimated cost of $728 per injection in 2018 US dollars) was not cost-effective if it yielded only a 1-year delay of TKA. However, from a societal perspective (which considered both lost productivity and the need for unpaid caregiving associated with TKA surgery), PRP was cheaper over a lifetime because it delayed direct and indirect costs associated with TKA. The ICER for TKA at the outset was $4,175 per QALY, which is well below the predetermined willingness-to-pay threshold of $50,000. The authors emphasize that this favorable ICER reflects the improved quality of life after TKA compared with published results of PRP injections for knee OA.

Rajan et al. do specify a clinical scenario in which PRP may have a cost-effectiveness advantage over TKA: “…in a higher-risk patient population in whom the perioperative complication rates, TKA revision rate, or postoperative functional outcomes are projected to be worse.”

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.

 

3D-Printed Endoprosthesis Yields Promising Early Results

Tumor resections from the pelvic girdle often pose daunting reconstruction challenges for orthopaedic surgeons. In the September 2, 2020 issue of The Journal of Bone & Joint Surgery, Ji et al. report early results from a series of 80 bone-tumor patients who underwent pelvic reconstruction using a 3D-printed modular hemipelvic endoprosthesis. The 3D-printed interconnected porous component was generated from an electron beam melting process, and the design allowed for the main iliosacral fixation screws to be oriented parallel to the loading axis of the trunk.

The authors detected no acetabular component instability or implant loosening or migration after a mean follow-up of 32.5 months. The mean acetabular tilt on the reconstructed side immediately after surgery was 46.9o, and it was 47.1o at the most recent follow-up. The mean function score (84%, as measured by the Musculoskeletal Tumor Society 93 tool) was higher than the previously reported range of 55% to 72% from recent studies, and the authors say that the 3-month dislocation rate in this series (2.5%) “seems to be the lowest ever reported.” Moreover, histological analysis of specimens from 2 patients who experienced tumor recurrence revealed bone trabeculae extending toward the implant and bone ingrowth within the porous network.

Still, complications occurred in 16 (20%) of the patients, with wound dehiscence being the most prevalent one. Deep infections, relatively common after pelvic reconstruction surgery, occurred in 5 (6.3%) of the patients, which is a lower deep-infection rate than those reported in previous studies.

Despite the stable fixation and “satisfying early functional and radiographic outcomes” with this 3D-printed modular prosthesis, the authors caution that their short-term results “may prove to be insufficient for the assessment of implant viability.” Nevertheless, any innovation that helps address the many surgical challenges in this population of orthopaedic patients is welcome.

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.

Teamwork Necessary When Treating Patients with Syringomyelia + Scoliosis

Most orthopaedic spine surgeons and neurosurgeons have come to understand that syringomyelia plays a role in some cases of scoliosis, and that the spinal-cord condition may increase the risk of cord injury during deformity-correction surgery. In the August 19, 2020 issue of JBJS, Tan et al. investigate whether radiographic and clinical outcomes after 1-stage posterior spinal fusion to correct scoliosis secondary to syringomyelia differ between patients with syringomyelia related to Chiairi-I malformation (CIM) and those with idiopathic syringomyelia.

The short answer is “no.” Although researchers found larger preoperative syringeal parameters in the CIM group, up through 2 years after scoliosis-correction surgery, they detected no significant between-group differences in coronal/sagittal parameters or in scores from the 5 domains of the Scoliosis Research Society-22 questionnaire. Moreover, the preoperative neurological status and intraoperative neuromonitoring signals were similar in both groups.

In commenting on these findings, Kent A. Reinker, MD, points out that patients who had received preoperative neurological treatment for the syrinx were excluded from the study, so “the results … do not necessarily apply to patients who have had neurological intervention prior to scoliosis surgery.”  He strongly recommends that all patients with a syrinx be referred to a neurosurgeon for evaluation prior to any scoliosis surgery, concluding that “a working partnership between orthopaedic surgeons and their neurological colleagues is important when assessing these patients.”

Electronic Portal Usage among Orthopaedic Patients

Physician groups and hospitals have come to rely on electronic patient portals (EPPs) for many things, including appointment scheduling and reminders, delivery of test results, and pre- and post-visit information gathering from patients. Most of the research into the clinical efficacy and cost-effectiveness of EPPs has taken place in primary care and internal medicine settings. But in the August 5, 2020 issue of The Journal of Bone & Joint Surgery, Varady et al. examine the benefits of EPP use among patients undergoing orthopaedic procedures of various types. In the process, they also uncover racial and socioeconomic disparities in the use of EPPs.

The retrospective review of >18,000 patients (average age of 56.9 years) undergoing an orthopaedic procedure at 2 Boston-area academic hospitals found a veritable 50-50 split between those who used the EPP and those who did not. Relative to white patients, African-American and Hispanic patients were significantly less likely to use the EPP. Other demographic factors associated with portal nonuse were non-English speaking, male sex, low income, and having less than a college education.

Multivariable regression analysis demonstrated that, relative to EPP nonuse, EPP use was associated with significantly lower no-show rates, increased odds of completing one or more patient-reported outcome measures (PROMs), and improved overall patient satisfaction. The degree of after-surgery functional improvements measured with PROMs was the same among EPP users and nonusers.

The authors home in on the benefits of the 27% reduction in missed appointments this study divulged. First and foremost, missed appointments have been shown to negatively affect patient outcomes. On the provider side, no-shows increase staff frustration and cost time and money. (The 2 hospitals realized a combined estimated $200,000 in savings over 1 year from the reduction in no-shows.) Consequently, Varady et al. say that “the benefit of reducing missed appointments alone may be sufficiently strong to warrant efforts to increase EPP enrollment.”

Increased efforts among orthopaedic office staff and clinicians to enroll patients in portal usage during their hospital stay or during pre- or postoperative visits could also help address the disparity issue. “These results have important implications for the orthopaedic surgery community in…achieving more equitable care,” the authors conclude.