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November 2018 Article Exchange with JOSPT

In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of November 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior.

This observational cohort study found that patients who used more health care prior to hip arthroscopy also used more health care after surgery. The findings lead the authors to conclude that clinicians “should consider prior patterns of health care utilization…when determining care plans and prognosis.”

October 2018 Article Exchange with JOSPT

jospt_article_exchange_logo1In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.

This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.

Team Physicians Finally Get Federal Licensing and Liability Protection

Capitol Dome for OBuzzWhen it comes to passing federal legislation on Capitol Hill, common-sense solutions for relatively straightforward problems are often not easy to come by. There always seems to be something holding up every piece of legislation, no matter how great the benefits and how minimal the risks/costs.

That is why I was happy to hear that Congress passed the Sports Medicine Licensure Clarity Act  earlier this month.  The legislation clarifies that health care services provided by a licensed provider in a state other than the one in which he/she is licensed (a scenario commonly encountered by physicians and athletic trainers who travel with collegiate or professional athletic teams) will be considered in-state services and will be covered by the provider’s liability insurance.

The American Association of Orthopaedic Surgeons (AAOS) and several other provider groups—including the American Orthopaedic Society for Sports Medicine (AOSSM)—have long recognized that previous laws exposed many team physicians to medical liability if they provided care in states in which they did not have a medical license. The Clarity Act protects orthopaedic surgeons, athletic trainers, and other health care professionals who serve as traveling care providers from licensure hassles and potential liability so they can focus on caring for their athlete-patients.

As someone who has been engaged in orthopaedic advocacy efforts for my entire, albeit short, orthopaedic career, I am proud of this accomplishment. Advocacy is not for the faint of heart, and the amount of work that goes on behind the scenes to get legislation like this enacted is astounding. Arguably, such efforts have never been more important than they are in today’s health care environment.  If we, as orthopaedic surgeons, do not advocate on behalf of our patients and ourselves, no one else will.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

JBJS Essential Surgical Techniques and JBJS Open Access Now in PubMed Central

PMC LogoThe Editors of The Journal of Bone & Joint Surgery (JBJS) are pleased to announce that JBJS Essential Surgical Techniques (EST) and JBJS Open Access (OA) are now archived in PubMed Central (PMC), the national repository of free full-text biomedical literature, and discoverable on PubMed.

Launched in 2011 and edited by Edward Cheng, MD, JBJS Essential Surgical Techniques offers readers an expanding online library of thoroughly vetted orthopaedic procedures, including high-quality instructional videos. Peer reviewed and derived from top-quality published clinical studies, EST articles and videos deliver detailed, practical surgical guidance to all orthopaedists—from seasoned practitioners to those just starting out in practice.

Launched in 2016, JBJS Open Access gives authors an open-access option bolstered by the outstanding service and editorial excellence that JBJS has delivered for more than 125 years. At the same time, orthopaedic clinicians and researchers worldwide benefit from all-inclusive access to the best clinical and basic-science content about musculoskeletal health and injury care. JBJS OA is co-edited by Eng Lee, MD, FRCSC and Robin Richards, MD, FRCSC.

To learn more about JBJS Essential Surgical Techniques, click here.

To learn more about JBJS Open Access, click here.

Call for Submissions: JBJS What’s Important Articles

Warren WI for OBuzzOver the last two years, JBJS has published more than 20 What’s Important articles, with topics ranging from unhappy patients to innovations in orthopaedic education. In these 1,000-word articles, clinicians tell a thoughtful and personal story about a high-impact lesson they learned at some juncture in life that altered their worldview, enhanced them personally, and positively affected the care that they provide as orthopaedic physicians.

Because they are personal in nature, “What’s Important” submissions are not subject to the usual stringent peer-review process. Instead, they are reviewed by the Editor-in-Chief, who  corresponds with the author if revisions are necessary and makes the final decision regarding acceptance. The accepted manuscript is then forwarded to JBJS staff for copyediting and publication.

Authors of these articles have received many comments suggesting that readers value What’s Important articles in unique ways. If you would like JBJS to consider a “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.

Impact of Clinical Practice Guidelines on Use of Injections for Knee OA

Knee Injection for OBuzzIn a recent OrthoBuzz post, I commented on the apparent benefits to patients when Scottish hip-fracture guidelines were followed. Now, in a “closer-to-home” study in the May 16, 2018 issue of JBJS, Bedard et al. examine the effects of AAOS clinical practice guidelines (CPGs) on the use of injections for knee osteoarthritis (OA). The authors used an insurance database housing more than 1 million knee OA patients to evaluate the change in rates of corticosteroid and hyaluronic acid injections from 2007 to 2015. This date range includes the periods before and after the publication of the AAOS CPGs for knee arthritis (both the first edition, published in early 2009, and the second edition, published in late 2013).

The authors found that the rate of hyaluronic acid injections by orthopaedic surgeons decreased significantly after both publications of the guidelines and that the utilization of corticosteroid injections appears to have plateaued since the most recently published guidelines. Still, almost 40% of all of the patients in the cohort received a corticosteroid injection, with 13% having received a hyaluronic acid injection. In absolute numbers, those percentages represent more than half a million injections, despite the facts that the evidence supporting either injection for the treatment of knee OA is weak at best and that almost half of the patients receiving one of these injections ended up getting a total knee replacement within a year.

While the changes in practice revealed by Bedard et al. may seem relatively small, they are a step in the right direction toward value-based care.  CPGs are easy to pick apart, but they are developed carefully and for a good reason—to provide us with evidence-based recommendations for excellent patient care. It is gratifying to see that such guidelines are having a positive impact in our field.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

May 2018 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of May 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Quality of Life in Symptomatic Individuals After Anterior Cruciate Ligament Reconstruction, With and Without Radiographic Knee Osteoarthritis.”

The authors conclude that diagnosing radiographic osteoarthritis in symptomatic individuals after ACL reconstruction may be valuable, because targeted strategies to facilitate participation in satisfying activities have the potential to improve quality of life in these patients.

More Progress in Preventing Secondary Fragility Fractures

ownbone_logo-rHow well do fracture liaison services (FLSs) work in terms of patients who’ve had a fragility fracture receiving a recommendation for anti-osteoporosis treatment? Very well, according to findings from an analysis of more than 32,000 patients by Dirschl and Rustom in the April 18, 2018 edition of The Journal of Bone & Joint Surgery.

A fracture liaison service is a coordinated, multidisciplinary model of care designed to reduce the risk of future fractures among patients who’ve sustained a primary fragility fracture. (Click here for another recent JBJS article about the FLS model.) The American Orthopaedic Association (AOA) has been a major proponent of the FLS model, and it is a cornerstone of the AOA’s “Own the Bone” national quality-improvement program.

Dirschl and Rustom found that between 2009 and 2016, at 147 sites participating in an FLS through Own the Bone, 72.8% of 32,671 patients initially evaluated for a fragility fracture received a recommendation for anti-osteoporosis treatment. That’s a vast improvement compared with previous reports that indicate only 20% of patients with a fragility fracture received either an osteoporosis evaluation or treatment. In this current study, a sedentary lifestyle and having a parent who had sustained a hip fracture were the patient factors associated with those most likely to receive a recommendation for treatment.

OrthoBuzz editors were surprised to read that anti-osteoporosis treatment was initiated in only 12.1% of the patients in this study. When we asked JBJS Editor-in-Chief Marc Swiontkowski, MD for a further explanation, he noted that the study captured data only from the initial post-fracture encounter between patients and FLS clinicians. The percentage of patients initiating treatment would have been much higher, he said, if the data had included those who followed up their initial FLS evaluation with a primary care physician. He also remarked that some people are dissuaded from taking an FDA-approved prescription anti-osteoporosis medication by the disproportionate focus on side effects that patients read in social media and the lay press. And there are some patients for whom prescription anti-osteoporosis drugs are truly contraindicated.

But with an estimated 2 million people in the US sustaining a fragility fracture each year, these results indicate substantial progress in practices that will prevent secondary fractures.

Click here for a listing of upcoming Own the Bone events.

Childhood Toe-Walking: Usually a Transient Condition

Toe Walking for OBuzzParenting is a lot like medicine. Parents seek to “fix” their children, and physicians seek to “fix” their patients. However, sometimes the best “fix” is to observe closely, do nothing, and let nature take its course. That’s the main conclusion of the study by Engstrom et al. in the April 18, 2018 edition of JBJS. The authors set out to document the natural history of idiopathic toe-walking to determine how often the condition resolves without intervention.

After analyzing a cohort of more than 1,400 children, the authors found that 63 (5%) had been toe-walkers at some point as a toddler—but that almost 80% of those children spontaneously ceased being toe-walkers by the time they were 10 years of age.  However, the authors found that children with ankle contractures before age 5 were unlikely to spontaneously cease toe-walking and would benefit from early surgical intervention. This study also demonstrated a correlation between neurodevelopmental comorbidities and toe-walking. Although 4 of the 8 children who still toe-walked at 10 years of age had received a neurodevelopmental diagnosis between the ages of 5.5 and 10 years, the authors state that “even in this subgroup of children, the idiopathic toe-walking seems, for the majority of children, to be a transient condition.”

Taken as a whole, this Level-I prognostic study provides relatively clear treatment pathways for clinicians and parents to follow when a child presents with toe-walking. The findings can be used to help calm the fears of parents regarding their child’s development while also giving surgeons the confidence to treat the majority of these children with observation unless there is a contracture of the calf musculature.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Fifth Anniversary of Boston Marathon Bombing

SpecialReportII-Cover-FinalOn the eve of the 2018 Boston Marathon, we wish all the participants a safe run tomorrow. And we remember all those who are still experiencing the aftermath of the 2013 Marathon Bombing.

Not a single person who reached a Boston hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients. Click here to download the report for free.

We  thank the many people whose dedication to disaster-preparedness helps ensure that the 2018 and future Boston Marathons will go on.