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Defining Success in an Orthopaedic Career

Warren WI for OBuzzThe December 6, 2017 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Dr. Steven B. Warren.

Dr. Warren ponders whether his decision to jettison an “academic pedigree” in favor of a private practice in western Florida was a good career choice. In answering that question with a resounding “yes,” Dr. Warren’s essay reminds readers that the definition of “success” is intensely personal. In his case, what matters most is being a solid orthopaedic diagnostician and surgeon, a loving father and husband, a philanthropist, and a respected member of his religious and secular communities.

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

Unprecedented Access and Discoverability on the New JBJS.org

Home Page Search

I’m constantly searching for JBJS content to do my job at The Journal. That’s why I’m thrilled with the power, speed, and accuracy of the new search engine that’s at the heart of the reimagined and reengineered jbjs.org.

Here are just a few examples of what happens when you use the “enter a search query” bar at the top of every page on the new website:

  • As you type a common orthopaedic word, such as distal, you get a drop-down list of popular terms with that word included. Very often, what you’re looking for is in the list, so you can stop typing and simply click. (This works just like a popular feature in an often-used search engine that I won’t name here.)
  • When you search a phrase or condition, such as distal radial fracture, you get relevant articles, images, videos, webinars, and podcasts from the flagship JBJS, as well as from JBJS Essential Surgical Techniques, JBJS Reviews, JBJS Open Access, and JBJS Case Connector. You can also easily filter your results by publication name.
  • If you know the digital object identifier (DOI) of a JBJS article of interest, simply paste it into the search bar (beginning with the numeral 10), and you’ll get that specific result. The same holds true for complete or partial article titles, even if they are long.
  • When you search for an author by last name, your top hits are articles in which that name appears as an article author, rather than articles in which it appears in the reference list.
  • Once you’ve found what you’re looking for, click on the star icon to automatically save the item to your customized “My JBJS” folder.

In developing this improved search experience, JBJS listened to a broad array of orthopaedic website users, young and old. Over the last five-plus years, this (old) user has searched for JBJS content on four different platforms using four different search tools, and this one is by far the most satisfying.

Complimentary access to the new jbjs.org is available until March 1, 2018.

Lloyd Resnick
JBJS Developmental Editor

JBJS: Aiding and Abetting Orthopaedic Residents

Resident Resources CaptureNo matter how you look at it, orthopaedic residency is a relentlessly challenging five or six years. The Journal of Bone & Joint Surgery offers the following special services to make life and learning a little easier for orthopaedists in training:

Residents who connect now with JBJS establish a solid foundation for a career of lifetime orthopaedic learning. Click on the “Residents” button under “Editorial Resources” at www.jbjs.org to find out more.

More Data on Outpatient vs Inpatient Joint Replacement

TKA for OBuzzIn addition to the Pearl Diver-based retrospective study by Arshi et al. on one-year complications after outpatient knee replacement, the December 6, 2017 issue of JBJS contains a NSQIP-based retrospective study by Basques et al. that compares 30-day adverse events and readmissions among 1,236 patients who underwent same-day-discharge hip or knee (total or unicompartmental) arthroplasty with an equal number of propensity score-matched patients who were discharged at least 1 calendar day after the procedure.

When analyzing all three procedures together, the authors found no overall between-group differences in the rates of any adverse event (severe or minor) or readmission. However, when authors analyzed individual adverse events, the same-day group had decreased thromboembolic events and increased 30-day reoperations compared to inpatients. Analysis of individual procedures revealed an increased 30-day reoperation rate for same-day total knee arthroplasty (TKA), compared with inpatient TKA. Overall, infection was the most common reason for reoperation and readmission following same-day procedures.

As with the Arshi et al. study, the limitations of the database prevented these authors from accounting for physician or hospital volume. However, they did identify several preoperative patient characteristics that increased the risk of 30-day readmission among same-day patients, and from those findings Basques et al. concluded that “obese patients, older patients [≥85 years of age], and those with diabetes mellitus may not be appropriate candidates for same-day procedures.”

Modern Irrigation/Debridement Yields Good Results for Early Post-THA Infection

Hip Debridement for OBuzzNowadays, chronic deep periprosthetic joint infections (PJIs) are typically treated with 2-stage exchange arthroplasty, but what about acute PJIs? In the December 6, 2017 edition of JBJS, Bryan et al. report on a retrospective cohort study of acute infections after hip arthroplasty. The results suggest we’ve come a long way in identifying patients with early infections and that contemporary irrigation-and-debridement protocols are more successful than older methods.

The researchers studied 6-year outcomes in 90 hips that had undergone either total or hemiarthroplasty and that were determined to have either acute early postoperative infections (n=66) or acute hematogenous infections (n=24). All the infected hips were managed with either irrigation, debridement, and modular head and liner exchange (70%) or with irrigation and debridement alone (30%). The authors stratified the patients into those without comorbidities (A), those with 1 or 2 comorbidities (B), and those with >2 comorbidities (C). Postoperatively, patients were treated with broad-spectrum intravenous antibiotics, followed by targeted therapy administered by infectious disease specialists.

Of the 90 acute infections, failure—defined as uneradicated infection, subsequent removal of any component for infection, unplanned second wound debridement for ongoing infection, or infection-related mortality—occurred in 15 hips (17%). Of those 15, 9 required component removal. The chances of treatment failure were slightly higher in cases of hematogenous infection (21%), compared with acute early postoperative infection (15%), but that difference was not statistically significant. Significant comorbidity-related failure-rate differences were found: failure occurred in 8% of the grade-A patients, 16% of grade-B patients, and 44% of grade-C patients. The most common infecting organism was methicillin-sensitive Staphylococcus aureus (MSSA).

From this overall 6-year success rate of 83%, the authors conclude that “with modern inclusion criteria for acute infection, modern surgical techniques, and modern antibiotic therapy…the rate of success was higher than in most historic reports.”

Webinar on Dec. 13—Patient Satisfaction After ACL Surgery

webinar speakersAn estimated 300,000 ACL surgeries are performed in the US annually, at an estimated cost of up to $1 billion, but we still have many unanswered questions about patient satisfaction after these procedures. Among them:

  • Does the cost of postoperative physical therapy affect patient satisfaction?
  • What are the rates and predictors of return to play after ACL reconstruction? Does graft choice play a role?
  • What is the relationship between return to play and patient satisfaction?

On Wednesday, December 13, 2017 at 8:00 PM EST, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary* LIVE webinar that addresses these and other important questions.

JOSPT co-author Caitlin J. Miller, PT, DPT and JBJS co-author Benedict U. Nwachukwu, MDMBA, will discuss findings from their respective studies, and the webinar will include additional insights from Mark V. Paterno, PT, PhD, MBA, SCS, ATC, and Elizabeth Matzkin, MD. Moderated by Tara Jo ManalPT, DPT, OCS, SCS, FAPTA, the webinar will conclude with a live Q&A session between the audience and panelists.

Seats are limited so REGISTER NOW.

*All registrants will have free access to the webinar for 24 hours following the live broadcast.

The Rapid Growth of Orthopaedics in China

WI Banner for OBuzz

The November 1, 2017 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Dr. Cyril Mauffrey.

Having grown up in Hong Kong and Singapore, Dr. Mauffrey juxtaposes the economic growth in China over 35 years with the transformation during the last decade in the practice of orthoapedics in this land of 1.4 billion people. With both a personal and professional perspective, he explains how China has adapted orthopaedically—with the help of the Chinese Orthopaedic Association, AO Asia Pacific, and several pioneering individuals—to “standardize care and promote clinical excellence and innovation across the nation.”

If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.

Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.

Patient Satisfaction After ACL Reconstruction—Dec. 13 Webinar

webinar speakersWe still have many unanswered questions about patient satisfaction after anterior cruciate ligament (ACL) reconstruction.

  • Do specific patient populations benefit from more or fewer physical therapy (PT) visits?
  • Does the cost of PT affect patient satisfaction?
  • Should patients be classified by factors beyond their medical diagnoses to achieve the best outcomes while minimizing costs?
  • What are the rates and predictors of return to play after ACL reconstruction? Does graft choice play a role?
  • What is the relationship between return to play and patient satisfaction?

On Wednesday, December 13, 2017 at 8:00 PM EST, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary* LIVE webinar that addresses these important and clinically applicable questions.

JOSPT co-author Caitlin J. Miller, PT, DPT, will share the results of a retrospective cohort study examining the relationship between patient demographics, number of physical therapy visits, and the cost of postoperative interventions with revision rates and patient-reported outcomes following primary ACL reconstruction.

JBJS co-author Benedict U. Nawachukwu, MD, MBA, will discuss findings from a study  of return to play and patient satisfaction among athletes following ACL reconstruction. This study also explores the efficacy of patellar tendon autografts and the preinjury impact of certain sports.

Moderated by Tara Jo Manal, PT, DPT, OCS, SCS, FAPTA, a leading authority on the spine and the knee, the webinar will include additional insights from expert commentators Mark V. Paterno, PT, PhD, MBA, SCS, ATC, and Elizabeth Matzkin, MD. The last 15 minutes will be devoted to a live Q&A session between the audience and panelists.

Seats are limited so REGISTER NOW.

*All registrants will have free access to the webinar for 24 hours following the live broadcast.

Fructosamine Bests HbA1c for Preop Glycemic Screening

Fructosamine for OBuzzPatients with diabetes have an increased risk of postoperative complications following total joint arthroplasty (TJA). Additionally, perioperative hyperglycemia has been identified as a common and independent risk factor for periprosthetic joint infection, even among patients without diabetes. Therefore, knowing a patient’s glycemic status prior to surgery is very helpful.

In the November 15, 2017 edition of The Journal of Bone & Joint Surgery, Shohat et al. demonstrate that serum fructosamine, a measure of glycemic control obtainable via a simple and inexpensive blood test, is a good predictor of adverse outcomes among TJA patients—whether or not they have diabetes.

Researchers screened 829 patients undergoing TJA for serum fructosamine and HbA1c—a common measure, levels of which <7% are typically considered good glycemic control. Patients with fructosamine levels ≥292 µmol/L had a significantly higher risk of postoperative deep infection, readmission, and reoperation, while HbA1c levels ≥7% showed no significant correlations with any of those three adverse outcomes. Among the 51 patients who had fructosamine levels ≥292 µmol/L, 39% did not have HbA1c levels ≥7%, and 35% did not have diabetes.

In addition to being more predictive of postsurgical complications than HbA1c, fructosamine is also a more practical measurement. A high HbA1c level during preop screening could mean postponing surgery for 2 to 3 months, while the patient waits to see whether HbA1c levels come down. Fructosamine levels, on the other hand, change within 14 to 21 days, so patients could be reassessed for glycemic control after only 2 or 3 weeks.

While conceding that the ≥292 µmol/L threshold for fructosamine suggested in this study should not be etched in stone, the authors conclude that “fructosamine could serve as the screening marker of choice” for presurgical glycemic assessment. However, because the study did not examine whether correcting fructosamine levels leads to reduced postoperative complications, a prospective clinical trial to answer that question is needed.