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Journal Club Resident Spotlight: Praharsha Mulpur

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The grant program promotes career-long skills in evaluating the orthopaedic literature. Click here for more information.

Name: Praharsha Mulpur, MD

Affiliation: Sunshine Bone and Joint Institute, Hyderabad, India

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

Tuberculosis (TB) of the hip joint is still prevalent in India. We are often faced with situations of advanced destruction of the hip joint requiring total hip replacement (THR), but THR is usually delayed until the disease condition becomes quiescent. However, TB is known to persist subclinically and to reactivate after surgery. One of the journal club articles we discussed was a “practice changer” as far as THR in active TB was concerned: Kim et al. Total hip replacement for patients with active tuberculosis of the hip. Bone Joint J, 2013; 95-B:578-82.

What are the top 3 characteristics of an engaging, enlightening journal club presentation?

The most important characteristics include: (1) Clinical relevance: The article chosen should generate discussion on a topic that is clinically relevant and not one that has already been “settled” or “dismissed.” Not all “historical” articles are clinically relevant in the 21st century. (2) Participation: Participants should be well-versed with the topic prior to the meeting, which allows detailed discussion with different perspectives. (3) Brevity: Presentations of the article(s) being discussed should be clear and concise.

Aside from orthopaedic content, what have you been reading lately?

I am following several podcasts, both clinical and nonclinical. I am also reading articles from the Farnam Street blog by Shane Parrish, The New York Times, and a nonfiction book titled Nothing to Envy by Barbara Demick.

How has the COVID-19 pandemic affected your journal-club activities?

Unfortunately, our in-person journal clubs have been halted due to the ongoing risk of COVID transmission, and our institute and department have adopted a completely virtual academic program. This has advantages and disadvantages. On the positive side, we are able to involve senior faculty, both national and international, to participate in the journal club discussions. Apart from our monthly internal journal club, we have an ongoing academic relationship with the department of orthopaedics at the University of Miami for a monthly journal club. With this, our residents and fellows gain international perspectives on topics of clinical significance. On the downside, nothing beats an in-person meeting. Group dynamics and participation are always better in a room than on a Zoom screen.

How has free access to JBJS Clinical Classroom benefited you and your journal club?

JBJS Clinical Classroom is a valuable educational resource and is highly recommended for orthopaedic residents. The content is excellent and helped me cover a lot of topics without having to go back to a reference textbook. The progress meter is useful to assess personal progress. One of the best features is the JBJS Clinical Classroom Library. Every topic has links to the best or most-cited references, which makes studying easy.

Journal Club Resident Spotlight: Agustin Albani Forneris

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The grant program promotes career-long skills in evaluating the orthopaedic literature. Click here for more information.

Name: Agustin Albani Forneris, MD

Affiliation: Hospital Italiano de Buenos Aires, Argentina

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

Many articles presented in our journal club ignited debate, not only about their findings but also their design and methodology. One standout was the article by Matsunaga et al. (Minimally Invasive Osteosynthesis with a Bridge Plate Versus a Functional Brace for Humeral Shaft Fractures: A Randomized Controlled Trial. J Bone Joint Surg Am. 2017 Apr 5;99[7]:583-592), which is a prospective randomized study comparing minimally invasive osteosynthesis vs functional bracing for the treatment of humeral shaft fractures. It is quite unusual that a Level-I prospective study like this was designed in Latin America. Our debate focused primarily on identifying which patients in our population would benefit from one treatment or another, in order to apply specific indication criteria to our daily practice. In turn, several hypotheses were raised that stimulated ideas for future projects.

Based on your journal club experiences, what are the top 3 characteristics of an engaging, enlightening journal club presentation?

(1) The commitment of the participants. We encourage all of our 43 residents to not only read the article in advance but also to write a critical review as if they were reviewers of a journal.

(2) Selection of the article. We encourage residents to select controversial studies that trigger debate about results and methodology. It is often valuable to criticize an article whose methodology is controversial to analyze which aspects would make the same study more solid (i.e., selection bias, randomization, data collection, statistical analyses, etc.)

(3) Inviting an experienced faculty surgeon. This is always inspiring to all residents, helping us to write and review articles and transmitting to us their passion for research.

Aside from orthopaedic content, what have you been reading lately?

I am a technology fan, so I usually read specialized magazines on electronic devices and reviews about new gadgets on the market. During holidays, I love to read historical novels that transport me to another place and time. Reading about the achievements of people living at a time when life expectancy did not exceed 30 years amazes me.

How has the COVID-19 pandemic affected your journal-club activities?

Paradoxically, the pandemic empowered our journal-club activities. The substantial decrease in elective surgery to prioritize medical resources for Covid-patients, in addition to the proliferation of virtual applications, gave residents more accessibility to and availability for academic activities. The pandemic also enabled several staff surgeons to join our program, and that enriched the discussions.

How has your free access to JBJS Clinical Classroom benefited you and your journal club?

JBJS Clinical Classroom provides us the opportunity to link one of our most valuable learning tools with the journal club by synchronizing the topics from the resident program classes with the selected journals. JBJS Clinical Classroom also enables us to individualize each resident’s progress and to reinforce the areas that present the greatest difficulty.

STAR Ankle Component Fracture: Awareness, Not Alarm

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent “safety communication” from the FDA, the following commentary comes from Ariel Palanca, MD; Adam Bitterman, DO: and Christopher Gross, MD.

During the past decade, total ankle replacement (TAR) has been challenging the gold standard of ankle fusion for treatment of end-stage ankle arthritis. Improvements in TAR component design and refined surgical techniques have led to more predictable and reproducible outcomes.

On March 15, 2021, however, the US Food and Drug Administration (FDA) released a Safety Communication about the Scandinavian Total Ankle Replacement (STAR Ankle), a product line that DJO Surgical acquired from Stryker in November 2020. The FDA’s statement cites a “higher than expected” rate of fracture of the device’s mobile-bearing polyethylene component. The communication goes on to suggest that patients younger than 55 years old and those with an active lifestyle may have a higher risk of component fracture than older, more sedentary patients.

The STAR Ankle received premarket approval from the FDA in 2009, and the FDA is compiling data from 2 post-approval trials of the device. In August 2019, Stryker issued a safety notification regarding the higher-than-expected fracture risk for STAR polyethylene implanted before August 2014. The recent FDA safety notification states there may also be a high risk of fracture for STAR polyethylene components implanted after August 2014, although the agency’s notification acknowledges that “the long-term fracture rate is not known in devices manufactured after the 2014 packaging change.”

The “packaging change” mentioned above refers to the August 2014 changeover when STAR polyethylene started to be packaged in a foil pouch, which virtually eliminates oxidation of the polyethylene and should therefore reduce fracture rates. Additionally, many peer-reviewed journal articles have reported lower STAR-component fracture rates than those found in the post-approval trials at equal or longer follow-ups.

It’s also important to note that the 8-year follow-up FDA study that revealed a 13.8% cumulative polyethylene-fracture rate only included 87 of the 606 STAR patients in the clinical trial. Patients with complications are often more likely to follow up than those with no complications, creating a potential negative bias.

Still, to err on the side of caution, the FDA suggests that surgeons who treat and follow patients with a STAR implant closely monitor them–especially younger, more active patients–for potential component fractures until more post-approval data is analyzed to further clarify any risk.

Ariel Palanca, MD is an orthopaedic foot and ankle surgeon at Arch Health Medical Group in Escondido, California. Adam Bitterman, DO (@DrAdamBitterman) 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. Christopher Gross, MD is an orthopaedic surgeon specializing in foot and ankle disorders at the Medical University of South Carolina in Charleston and a member of the JBJS Social Media Advisory Board.

Outpatient Knee/Hip Arthroplasty Yields Fewer Adverse Events

The National Surgical Quality Improvement Program (NSQIP) database contains more than a half-million records of patients who received a total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or total hip arthroplasty (THA) from 2009 through 2018. Fewer than 4% of those procedures were done in an outpatient setting, but patient demand for outpatient arthroplasty is rising rapidly.

With retrospective data like that from NSQIP, the most meaningful comparisons between inpatient and outpatient procedures come through a propensity score-matched analysis. Propensity score matching pairs up patients in each group according to multiple factors thought to influence outcome. In a recent study in The Journal of Bone & Joint Surgery, Lan et al. used propensity score matching to compare inpatient and outpatient arthroplasty in terms of adverse events and readmissions.

What the Researchers Did:

  • Matched each outpatient case of TKA, UKA, and THA from the database with 4 unique inpatient cases based on age, sex, ASA class, race, BMI, type of anesthesia, and history of hypertension, smoking, congestive heart failure, and diabetes
  • Compared inpatient vs outpatient rates of 30-day adverse events (both minor and severe) and readmissions
  • Identified risk factors for adverse events and readmissions

What the Researchers Found:

  • For all 3 arthroplasty types, patients who underwent an outpatient procedure were less likely to experience any adverse event, when compared with those who underwent an inpatient procedure.
  • The above adverse-event findings held true when TKAs, UKAs, and THAs were analyzed separately.
  • Outpatient procedure status was an independent protective factor against the risk of adverse events.
  • For all 3 procedures, readmission rates were similar among inpatients and outpatients. (The 2 most common reasons for readmission were infections and thromboembolic events.)
  • Clinicians are probably (and reasonably) selecting healthier patients to undergo outpatient procedures, but 42% of the outpatient cohort had an ASA class ≥3, and 55% had a BMI ≥30 kg/m2.

In their abstract, the authors cited “increased case throughput” as one rationale for outpatient arthroplasty, but this study provides convincing evidence that adverse-event reduction is another compelling reason for certain patients to consider outpatient knee and hip procedures.

Outcomes of Joint-Preserving Surgery in RA-Affected Feet

Dramatic improvements in medical treatment of rheumatoid arthritis (RA) have led to marked reductions in joint damage and deformities. Consequently, surgical methods for treating RA-related foot problems have gradually evolved from joint-sacrificing to joint-preserving procedures. In a recent issue of The Journal of Bone & Joint Surgery, Yano et al. reported on outcomes of 105 feet in RA patients treated with joint-preserving methods followed up for a mean of 6 years.

What the Researchers Did:

  • Performed a proximal rotational closing-wedge osteotomy of the first metatarsal and modified shortening oblique osteotomies of the lesser metatarsals
  • Recorded Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and at latest follow-up
  • Measured hallux valgus angle (HVA), intermetatarsal angle (IMA), and medial sesamoid position before surgery, 3 months after surgery, and at the latest follow-up
  • Tracked delayed wound healing, hallux valgus recurrence, nonunion, and reoperations
  • Calculated Kaplan-Meier survivorship with reoperation as the endpoint

What the Researchers Found:

  • Surgery was associated with significantly improved median SAFE-Q scores, relative to preoperative values.
  • The average HVA, IMA, and grade of medial sesamoid positioning decreased significantly, compared with preoperative measurements.
  • Kaplan-Meier survivorship at 7 years was 89.5%.
  • Delayed wound healing was found in 20% of the feet (all wounds healed with nonoperative treatment), hallux valgus recurrence in 10.5% of the feet, and reoperation in 10.5% of the feet.

Yano et al. emphasize several advantages of joint-sparing over joint-sacrificing surgery: preserved range of motion, stability of the metatarsophalangeal joint, and improved plantar-pressure distribution. However, these advantages and the “satisfactory” long-term outcomes noted above come with substantial complications that foot-and-ankle surgeons will strive to address in the future.

Mouse Paws Good for Investigating Pyogenic Flexor Tenosynovitis

Although an infected finger may not sound like a big deal, the closed-space bacterial infection known as pyogenic flexor tenosynovitis (PFT) has been described as “one of the most devastating infections in the upper extremity.” PFT can rapidly spread from one digit to another, and the incidence of posttreatment complications—including adhesions and tendon tears—has been reported to be as high as 38%.

In a recent issue of JBJS, Qiu et al. report on a mouse model that could help us better understand the pathophysiology of PFT—and more efficiently test established and novel ways of treating it. Previous basic-science investigations into PFT have relied on avian models, but those have proven to be expensive and hard to scale and maintain.

What the Researchers Did:

  • Inoculated the tendon sheath of 36 male mouse hind-paws with bioluminescent forms of either Staphylococcus aureus or sterile saline
  • Monitored the infected and control cohorts for bioluminescence values and clinical signs such as digit swelling and body-weight reduction
  • Performed histological analysis of control and infected paws

What the Researchers Found:

  • A significant increase in bioluminescence in the infected group for the first 2 days after infection
  • Significantly lower weights in the infected animals compared with controls
  • Swelling, scar formation, collapse of the intrasheath space, and thickening of the tendon sheath itself in the infected group

Qiu et al. say this mouse model “could serve as a platform in further understanding the pathophysiology of PFT” and could help evaluate therapies aimed at reducing scarring and stiffness.

Click here to read the JBJS Clinical Summary on Infections of the Hand by Ryan Calfee, MD.

Better 24-Hour Pain Control with Periarticular vs. IV Steroids in TKA

Corticosteroids are commonly used in total knee arthroplasty (TKA) to reduce pain and prevent nausea. But are the effects of steroids different when administered locally rather than systemically? Hatayama et al. investigate this question in JBJS, where they report on a randomized controlled trial comparing periarticular injection with intravenous (IV) administration of corticosteroids. The authors assessed the drugs’ effects on pain control, the prevention of postoperative nausea, and inflammation and thromboembolism markers following TKA.

The 100 included patients were 50 to 85 years of age and underwent primary, unilateral TKA for osteoarthritis. Fifty patients were randomized to the intravenous group (10 mg dexamethasone IV 1 hour pre- and 24 hours postoperatively, along with periarticular placebo injection during the procedure), and 50 were randomized to the periarticular injection group (a 40-mg injection of triamcinolone acetonide during surgery, along with IV placebo 1 hour pre- and 24 hours postoperatively).

Patients in the periarticular injection group experienced better pain control at 24 hours postoperatively, both at rest and during walking. The antiemetic effect was similar and notable in both groups. The IV group showed a better anti-thromboembolic effect, as measured by prothrombin fragment 1.2 levels, but the incidence of deep venous thrombosis was low overall, each group having only 2 cases.

The authors also reported that, at 24 and 48 hours, interleukin-6 levels did not differ between the groups, while C-reactive protein (CRP) levels were significantly lower in the IV group. In contrast, 1 week after surgery, patients in the periarticular group had a significantly lower CRP. These inflammatory-marker findings lead Hatayama et al. to postulate that “the better [24-hour] pain control in the periarticular injection group was not because of reduced inflammation,” and they note that locally administered corticosteroids directly inhibit signal transmission in nociceptive fibers.

Life Expectancy Informs Choice of Hemi Implant after Femoral Neck Fracture

Predicting life expectancy is not an exact science. But estimating the remaining years of life in elderly patients with a femoral neck fracture may help orthopaedists determine whether to use unipolar or bipolar hemiarthroplasty components when surgically managing that population. So suggest Farey et al. in the February 3, 2021 issue of The Journal of Bone & Joint Surgery.

The relevant “magic number” for life expectancy after femoral neck fracture is 2.5 years. The authors arrived at that number by performing statistical analyses on nearly 63,000 cases of femoral neck fractures treated with either modular unipolar or bipolar hemiarthroplasty. Patients were in their early 80s on average at the time of surgery. The researchers focused on revision rates because reoperations in this vulnerable group of patients typically yield poor results.

There was no between-group difference in overall revision rate within 0 and 2.5 years after the procedure. However, unipolar hemiarthroplasty was associated with a higher overall revision rate than bipolar hemiarthroplasty beyond 2.5 years after surgery (hazard ratio [HR], 1.86).

Farey et al. also drilled down into reasons for revision and found that unipolar prostheses had a greater risk of revision for acetabular erosion, particularly in later postoperative time periods. Conversely, bipolar hemiarthroplasty was associated with a higher risk of revision for periprosthetic fracture, which the authors surmise might have arisen from the greater range of motion (and therefore activity levels) permitted by bipolar implants.

Although the authors did not perform a formal cost-benefit analysis related to this dilemma, they observed a nearly $1,000 USD price difference between the most commonly used bipolar and unipolar prostheses. Farey et al. therefore propose that the more expensive bipolar prosthesis may be justified for patients with a life expectancy beyond 2.5 years, but that the unipolar design is justified for patients with a postoperative life expectancy of ≤2.5 years.

Click here to listen to a 15-minute OrthoJOE podcast about this topic, featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski and OrthoEvidence Editor-in-Chief Dr. Mo Bhandari.

Click here to see a 3-minute Video Summary of this study.

Click here to read a JBJS Clinical Summary comparing total hip arthroplasty with hemiarthroplasty for displaced femoral neck fractures.

Surgical-Technique Videos Focus on Pediatric Fractures

Many orthopaedic surgeons who take emergency-department or trauma call are confronted with a pediatric patient presenting with a fracture. However, very few of those orthopaedists are pediatric subspecialists. In fact, Geisinger researchers recently reported that the median number of pediatric orthopaedists per state in the US is only 23 (range 0 to 134).

To address these demographic realities, JBJS Essential Surgical Techniques has launched a video-based, point-of-care resource to help any orthopaedic surgeon manage the most common pediatric fractures with the highest level of quality, helping ensure excellent outcomes for young patients and their parents. Most of the authors of these pediatric-focused procedural videos are members of CORTICES—a collaboration of pediatric orthopedic surgeons dedicated to improving the management of emergent orthopedic conditions through education, research, and development of optimal care guidelines.

Here are links to the 5 already-published video articles in this series:

Upcoming videos in this special series will cover the following 5 topics:

  • Screw Fixation of Pediatric Proximal Tibial Tubercle Fractures
  • Reduction and Internal Screw Fixation of Transitional Ankle Fractures
  • Flexible Intramedullary Nailing of Pediatric Femur Fractures
  • Intramedullary Fixation of the Ulna for Monteggia Fracture Management
  • Open Reduction and Internal Fixation of Pediatric Medial Epicondyle Humerus Fractures

JBJS Essential Surgical Techniques is the premier online journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, and utilizing video to optimize the educational experience, thereby enhancing patient care.

T-Scores for Diagnosing Osteoporosis: 3 Are Better Than 1

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

The World Health Organization (WHO) and the International Society for Clinical Densitometry (ISCD) define osteoporosis based on (DXA) measures of bone mineral density that are translated into T-scores. A T-score ≤ -2.5 at any 1 of the 3 commonly measured sites (lumbar vertebrae, femoral neck, and total hip) is considered diagnostic for osteoporosis, and a T-score between -2.5 and -1 is indicative of osteopenia. University of Pennsylvania investigators1 proposed that combining all 3 T-scores in a multivariate analysis would be “potentially more informative” than the common practice of using the single lowest T-score.

The investigators applied multivariate statistical theory to T-scores from a sample of 1,000 65-year-old white women. When both real data and simulation models were analyzed, the researchers found that more patients were diagnosed with osteoporosis using the multivariate version of the WHO/ISCD guidelines than with the current WHO/ISCD guidelines. The diagnoses of osteoporosis using this method were also associated with higher Fracture Risk Assessment Tool (FRAX) probabilities of major osteoporotic fractures (P=0.001) and hip fractures (P=2.2×10−6). The FRAX tool combines a patient’s history of fracture with age, sex, race, height, weight, and social habits such as smoking and drinking to determine the risk of a major facture in the next 10 years.

This study shows that statistically considering all 3 T-scores may reveal more cases of osteoporosis than using the single lowest T-score. The trick will be getting this insight into the hands—and minds—of those making radiologic interpretations of DXA findings.

Reference 

  1. Sebro R, Ashok S. A Statistical Approach regarding the Diagnosis of Osteoporosis and Osteopenia from DXA: Are we underdiagnosing osteoporosis? J. Bone Mineral Res Plus. In press