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Screening Orthopaedic Patients for Asymptomatic COVID-19

During the initial surge of COVID-19, symptomatic patients were thought to be mainly responsible for spreading the virus, and guidelines therefore focused on identifying and isolating patients with fever, cough, or shortness of breath. However, as the asymptomatic spread became better understood, the need for more widespread, consistent molecular testing protocols became evident—and this is especially important now that elective orthopaedic surgery has resumed. Performing a surgical procedure on an asymptomatic patient with COVID-19 could lead to contamination of the operating room and other hospital zones, possibly infecting staff and other patients.

In the latest JBJS fast-track article related to COVID-19, Gruskay et al. describe a protocol for universal PCR swab testing of all orthopaedic surgery admissions at their New York City hospital during the 3 weeks between April 5, 2020 and April 24, 2020. At that time, only urgent orthopaedic procedures were being performed. Swab testing of 99 patients revealed a high rate of COVID-19 infections—the majority of which were in patients with no symptoms. With these published findings, the authors “hope to… make a case for nasopharyngeal testing of all preoperative patients.”

During those 3 weeks in April, 7 (58.3%) of the 12 patients who tested positive for COVID-19 had no symptoms consistent with the infection on presentation, and only 1 of those patients had pneumonia that appeared on a preoperative chest radiograph. Three asymptomatic patients who tested positive developed postoperative hypoxia, with 2 requiring intubation.

In recommending routine preoperative PCR testing for orthopaedic patients, the authors acknowledge the high specificity but only moderate sensitivity of the swab test, “but few other practical options exist,” they say. Evidence suggests that CT evaluation is the most accurate diagnostic test for COVID-19 pneumonia, but its use for screening is impractical. Chest radiography is more widely available, faster, and cheaper and emits less radiation than CT, but the sensitivity for diagnosing COVID-19 pneumonia with radiographs is reported as only 70%.

JBJS Elite Reviewers: Updated

The JBJS Elite Reviewers Program publicly recognizes our best reviewers for their outstanding efforts. Reviewers who review 4 or more manuscripts per year, rarely decline an invitation to review a manuscript (responding within 48 hours), and complete highly graded reviews within 1 week are eligible for the program. Elite Reviewers receive the following benefits in recognition of their exemplary performance:

  • No submission fees for papers of which the reviewer is the first author (for 12 months)
  • Free CME credits for all reviews
  • Free online access to all JBJS publications
  • A letter to the reviewer’s department head from JBJS Editor-in-Chief, Marc Swiontkowski, MD, recognizing and commending the good work
  • Name recognition on the JBJS Elite Reviewers Program web page and on the JBJS masthead

JBJS also offers a Reviewer Resource Center to support all of our reviewers.

A sincere “thank you” to our latest group of  Elite Reviewers:

Julie Agel, MA, ATC
Donald D. Anderson, PhD
Leon S. Benson, MD
John Gerard Birch, MD, FRCSC
Keith Bridwell, MD
In-Ho Choi, MD, PhD
Peter A. Cole, MD, FAOA
Charles N. Cornell, MD
Brett D. Crist, MD
John M. Cuckler, MD
Thomas A. DeCoster, MD
Shivi Duggal, MD, MBA, MPH
Paul, J. Duwelius, MD, FAAOS
Nicholas J. Giori, MD, PhD
H. Kerr Graham, MD, FRACS
Allan E. Gross, MD, FRCSC, OOnt.
Iftach Hetsroni, MD
Nitin B. Jain, MD, MSPH
Charles M. Jobin, MD
Charles E. Johnston, MD
Grant Lloyd Jones, MD
Andrew P. Kurmis, FRACS(Ortho), FAOrthA, FFSTEd, AMA(M), CIME, PhD(Ortho), PGDip(SurgAnat), BMBS(Hons), BMedRad(Hons), BAppSc(MedRad)
William D. Lack, MD
Paul E. Levin, MD
Jonathan C. Levy, MD
Terence E. McIff, MBA, PhD
Harry A. McKellop, PhD
Dana C. Mears, MD, PhD
Peter O. Newton, MD
Steven A. Olson, MD
Peter G. Passias, MD, MS
Vincent D. Pellegrini Jr., MD
Per-Henrik Randsborg, MD, PhD
David Ring, MD, PhD
Scott Rodeo, MD
Cecilia Rogmark, MD, PhD
Peter S. Rose, MD
Matthew D. Saltzman, MD
Sophia N. Sangiorgio, PhD
Robert Cumming Schenck Jr., MD
Edward M. Schwarz, PhD
William F. Scully, MD, FAAOS
Howard Seeherman, PhD, VMD
Noam Shohat, MD
James B. Talmage, MD
Rupesh Tarwala, MD
James E. Tibone, MD
Daniel G. Tobert, MD
Thomas Parker Vail, MD
Roger van Riet, MD, PhD
Andre J. van Wijnen, PhD
Kelly G. Vince, MD
Arvind G. von Keudell, MD
Brian C. Werner, MD
David Alan Wong, MD, MSc, FRCSC
Jacques T. YaDeau, MD, PhD
Adolph J. Yates Jr., MD

Open-Access JBJS Supplement: Pain Management Research

In November 2019, OrthoBuzz promised readers more details from the Pain Management Research Symposium held that month (see related post), which was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Those details are now available in the form of a JBJS Supplement containing 12 articles generated from that convening of > 30 orthopaedic researchers and journal editors. The Symposium focused on the unique challenges of designing studies that will answer pressing questions about pain management related to musculoskeletal conditions and procedures.

The content of this open-access Supplement ranges from subspecialty-specific considerations in pain management to “complementary medicine” approaches. It culminates in 7 key “Recommendations for Pain Management Research,” all targeted to identifying effective pain-management strategies, not just elimination of opioids. Among those recommendations are the following:

  • Define all terms (such as “long-term opioid use”) precisely.
  • Quantify opioid use in morphine milligram equivalents (MMEs), and state how MMEs were calculated.
  • Precisely define the study population (including age, sex, and socioeconomic and cultural characteristics).
  • Mental/emotional risk factors–including depression, catastrophizing, expectations, and coping ability–should be studied.
  • Outcome measures should be patient-related, not just the number of pills taken.

JBJS would again like to thank NIAMS for its support and all Symposium participants and Supplement authors for their time and energy.

COVID-19 Patients: Better Breathing After Fracture Surgery

COVID-19 infections spread rapidly in northern Italy from February to April of 2020. During that time, the orthopaedic unit at Humanitas Gavazzeni Hospital in Bergamo focused on elderly patients with both a femoral neck fracture and COVID-19. In a fast-tracked JBJS study, Catellani et al. report on what happened to 16 COVID-19-positive patients who were admitted to the hospital’s emergency department with a proximal femoral fracture:

  • 3 patients died from severe respiratory insufficiency and multiple-organ failure before surgery could be considered or performed.
  • 10 patients underwent fracture surgery on the day after admission; 3 had surgery on the third day after admission to allow washout of direct thrombin inhibitors.
  • Oxygen saturation improved in all patients who underwent surgery except 1
  • Hemodynamic and respiratory stability was achieved in 9 patients at an average of 7 days postsurgery.
  • 4 patients who underwent surgery died of respiratory failure—1 on the first day after surgery, 2 on the third day after surgery, and 1 on the seventh day after surgery.

In general, the advantages of early treatment of proximal femoral fractures in the elderly include early mobilization and better pain control. On the other hand, orthopaedists consider severe respiratory insufficiency to be a contraindication to anesthesia and surgery. The anesthesiology team working with Catellani et al. recommended early surgery in these patients if their oxygen saturation was >90% and their body temperature was <38°C. Spinal anesthesia was used for all patients to avoid sedation and was combined with a peripheral femoral nerve block to achieve better pain management.

The authors concluded that most of these COVID19-positive patients who presented in less critical condition and underwent carefully planned and executed surgery for proximal femoral fractures experienced a notable stabilization of their respiratory parameters.

A Primer on Coding and Documentation for Telemedicine

Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.

The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”

Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.

It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”

Virtual-Meeting Best Practices from OrthoEvidence

In addition to medical appointments between physicians and patients, many medical meetings and conferences have moved to online platforms due to the COVID-19 pandemic. That prompted the OrthoEvidence team, led by renowned orthopaedic surgeon and researcher Mohit Bhandari, MD, to publish a 32-page, downloadable resource titled “Best Practice Recommendations for Virtual Meetings.”

The document—developed from extensive reviews of the literature and private and public-sector documents, consultation with experts, and stakeholder surveys—is designed to help guide healthcare and academic groups as well as policymakers and funders.

The guidelines are organized into 5 sections:

  • Preplanning Considerations
  • Planning
  • Accomplishing goals
  • Response
  • Engaging the audience for future activities

A virtual-meeting planning checklist, a helpful table of virtual-meeting platform vendors, and many other practical resources are included in the document’s 6 Appendices.

Insights into Frozen Shoulder Inflammation

You don’t need a PhD in molecular pathophysiology to appreciate the fact that inflammation is a complex biological process. And you don’t need to be a shoulder subspecialist in orthopaedics to realize that symptoms of frozen shoulder (aka idiopathic adhesive capsulitis, or IAC) are common presenting complaints among middle-aged patients, especially women. In the May 6, 2020 issue of The Journal of Bone& Joint Surgery, a retrospective case-control study by Park et al. reveals some new insights about the association between adhesive capsulitis and inflammation, with a specific focus on the inflammatory marker high-sensitivity C-reactive protein (hsCRP).

The authors analyzed blood-sample results from 202 patients diagnosed with IAC and 606 age- and sex-matched controls. In addition to hsCRP, Park et al. investigated HbA1c, cholesterol, triglycerides, inflammatory lipoproteins, thyroid-stimulating hormone, the ratio of triglycerides to HDL (TG/HDL), BMI, and diabetes.

Park et al. determine that a blood level of hsCRP  >1.0 mg/L is an independent marker for IAC. They also conclude that the relationship between hsCRP and other findings in this study confirms the associations between IAC and previously cited risk factors of diabetes and dyslipidemia. Based on the fasting-glucose and HbA1c findings in this study, the authors additionally conclude that hyperglycemia and insulin resistance—frequent precursors to type-2 diabetes—are also strong risk factors for IAC.

Taken together, the results suggest the presence of an additive inflammatory effect among medical comorbidities in patients with IAC. But in his Commentary on this study, Michael Khazzam, MD says that these results alone cannot be used in clinical practice to counsel patients being treated for IAC. Ideally, he says, these findings could help inform future work that might provide a reliable method to predict, early in the disease process, the severity of IAC and the expected timetable for complete resolution of symptoms.

Number of COVID-19 Infections: Vastly Underestimated?

Many scientists worldwide are engaged in predicting the course of the COVID-19 pandemic, but the exact nature of this disease and the “novel” virus that causes it remains largely mysterious.

The numbers of confirmed cases in media reports are dependent on the extent of testing, which has varied markedly from region to region in North America. The scientific community has cautioned policymakers not to rely entirely on “observable” data (i.e., testing-confirmed COVID-19 cases) because such measures are likely to under-report the extent of the problem. That’s one reason why orthopaedic surgeon Mohit Bhandari, MD and his colleagues applied machine-learning tools to estimate the number of “unobserved” COVID-19 infections in North America.

The authors’ stated goal was to contribute to the ongoing debate on detection bias (one form of which can occur when outcomes—infections in this case—cannot be reliably counted) and to present statistical tools that could help improve the robustness of COVID-19 data. Their findings suggest that “we might be grossly underestimating COVID-19 infections in North America.”

The authors’ estimates relied on 2 sophisticated analyses: “dimensionality reduction” helped uncover hidden patterns, and a “hierarchical Bayesian estimator approach” inferred past infections from current fatalities. The dimensionality-reduction analysis presumed a 13-day lag time from infection to death, and it indicated that, as of April 22, 2020, the US probably had at least 1.3 million undetected infections, and the number of undetected infections in Canada could have ranged from 60,000 to 80,000. The Bayesian estimator approach yielded similar estimates: The US had up to 1.6 million undetected infections, and Canada had at least 60,000 to 86,000 undetected infections.

In contrast, data from the Johns Hopkins University Center for Systems Science and Engineering on April 22, 2020, reported only 840,476 and 41,650 confirmed cases for the US and Canada, respectively. Based on these numbers, as of April 22, 2020, the US may have had 1.5 to 2.02 times the number of reported infections, and Canada may have had 1.44 to 2.06 times the number of reported infections.

The authors emphasize that the “real” number of asymptomatic carriers cannot be determined without widespread use of validated antibody tests, which are scarce. Bhandari et al. conclude that policymakers should “be aware of the extent to which unobservable data—infections that have still not been captured by the system—can damage efforts to ‘flatten’ the pandemic’s curve.”

8 Work-from-Home Tips

During the COVID-19 pandemic, perhaps the luckiest among us are working from home (WFH), although doing so brings multiple challenges. On yesterday’s Scholarly Kitchen blog, Gabe Harp, Digital Products & Software Services team leader at the MIT Press, shared 8 hard-learned tips for sane and successful WFH. Whether you work in healthcare or some other field, you should be able to apply at least a few of these practical pieces of advice.

His “favorite and most earnest” recommendation: trim 15 minutes from all your meetings. But Harp saves the most important WFH reminder for the end of his post: be grateful for stable employment in a relatively safe environment, reliable internet, good health, and the many other privileges that much of the world’s population lacks right now.

Impressive Long-term Outcomes in Revision TKA with Constrained Prostheses

Time is an enemy of all orthopaedic implants, just as it is the bane of native joints. It is therefore helpful to accurately measure how long and well specific implant types last. That is what Kim et al. have done with their 19-year follow up of 90 patients (107 knees) who underwent total knee arthroplasty (TKA) with a constrained condylar knee prosthesis. Their findings appear in the April 15, 2020 issue of The Journal of Bone & Joint Surgery.

Knee arthroplasty surgeons often choose constrained prostheses to improve joint stability in patients with ligament dysfunction, and the typically longer stems of these implants can also compensate for poor bone stock. Kim et al. evaluated the same patient population (mean age of 65 years; mean BMI of 26.9 kg/m2) that they reported on in an earlier study, finding the following outcomes after a mean follow-up of 19 years:

  • 96% survival in terms of mechanical failure
  • 91% survival in terms of reoperation for any reason
  • Patient-reported outcome scores that remained significantly improved from pre-revision values
  • Only 1 knee with osteolysis around a component

Among the few knees that required re-revision, 5 such operations were performed due to aseptic loosening and 4 due to infection. The authors note that these very good long-term results are similar to those in previous studies of revision TKAs using various implant types. Kim et al. attribute these findings to several possible factors:

  • Low prevalence of comorbidities, including obesity, among the patients
  • Excellent surgical technique, including good cementing and correct flexion and extension gaps
  • Use of compression-molded polyethylene