Cross-Cultural Mentorship in Orthopaedic Surgery
Source: Association of American Medical Colleges (AAMC).
A new JBJS “What’s Important” article by Dr. David N. Bernstein and Dr. Addisu Mesfin discusses cross-cultural mentorship in orthopaedics, offering their personal reflections as a Black mentor and White mentee.
As the authors state, “Recent events in the United States have magnified our society’s continued struggle to effectively address structural racism. While many within the medical community have pledged to tackle race-related injustices, much of the measurable progress will take time to quantify accurately. However, one of the ways in which positive change may happen, and happen more expeditiously, is through active efforts to recruit Black learners into medical school and residency programs so that the country’s physician workforce is truly more representative of the populations it serves. Indeed, many in medicine, including leaders within orthopaedic surgery, have turned their attention toward this critical mission… It is no secret that mentorship is crucial to the professional and personal development of physicians and scientists, especially as a means to improve real diversity and inclusion, not just the appearance of it…” Read the full article here.
Journal Club Resident Spotlight: Jacob Wilson
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: Jacob Wilson, MD
Affiliation: Emory University School of Medicine, Atlanta
What was the topic of the most “dynamic” journal club meeting you have had so far this year?
We recently held an arthroplasty-themed journal club that was well received. We discussed 4 different papers, but I found the discussion on 2 to be particularly interesting. This included a study on long-term outcomes of cemented versus cementless total knee arthroplasty[1] and a randomized controlled trial on the use of virtual physical therapy visits after total knee arthroplasty.[2] These studies were well-designed and stimulated lively discussion.
- Kim, Y.H., J.W. Park, and Y.S. Jang, The 22 to 25-Year Survival of Cemented and Cementless Total Knee Arthroplasty in Young Patients. J Arthroplasty, 2021. 36(2): p. 566-572.
- Prvu Bettger, J., et al., Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial. J Bone Joint Surg Am, 2020. 102(2): p. 101-109.
What are the top 3 characteristics of an engaging, enlightening journal club presentation?
In my experience, journal club can be one of the better educational opportunities as a resident. There are a few things that are critical to making this the case. 1) Obviously, everyone needs to read the articles that are being discussed. This goes a long way in making the journal club interactive and constructive. 2) Attendance, particularly by faculty, is critical. I have found that when faculty from a variety of subspecialties attend, good discussions are generated. 3) Proper article selection. While landmark papers are important and should be reviewed by all residents, for the purposes of journal club, recent, clinically applicable articles that have the potential to change practice seem to be more interesting to those in attendance.
How has the COVID-19 pandemic affected your journal-club activities?
Like essentially all aspects of our lives, COVID-19 significantly changed our journal-club activities over the past year. Given national, regional, and institutional guidelines, our program moved all educational activities, including journal club, to virtual formats. While different than what we were previously accustomed to, this has made attendance easier for some faculty. That said, we are looking forward to a return to some degree of academic normalcy when we are able.
Aside from orthopaedic content, what have you been reading lately?
I’ve admittedly slacked on reading outside of orthopedics during residency. However, I have always been a fan of narrative nonfiction and am currently reading Dead Wake by Erik Larson.
How has free access to JBJS Clinical Classroom benefited you and your journal club?
I have found JBJS Clinical Classroom to be a good resource. As I prepare for Part I of my board exam, Clinical Classroom has been an easy and nice way to review concepts quickly. The app has made it easy to quickly do a few questions between cases. The content in Clinical Classroom is linked to primary literature, and this has led to some articles being selected for discussion at journal club.
Loss of Supination Force with Partial Distal Biceps Avulsion
In the May 5, 2021 issue of JBJS, Tomizuka et al. report the results of mechanical testing in which they quantified the loss of supination and flexion strength after a series of surgical releases designed to simulate traumatic avulsions of the short and long head of the distal biceps tendon.
Reflecting on the clinical implications of their study, the authors note:
Partial tears of the distal biceps tendon can cause substantial disability, yet the mechanical effect of such ruptures is not fully understood. This study showed that a simulated complete short-head tear significantly decreased (p ≤ 0.043) the supination moment arm by 24% in pronation and 10% in neutral.
A mechanical case can be made for early repair of a partial distal biceps tendon tear when the rupture is ≥75% of the distal insertion site.”
Click here for the full JBJS report.
A JBJS Clinical Summary on distal biceps tendon rupture can be found here.
A New Venue for Dr. Nelson’s Basic Science Tips
Based on page-view data, the monthly basic science posts from Fred Nelson, MD have been hugely popular on OrthoBuzz over the last 4-plus years.
Now, OrthoBuzz readers can sign up to receive Dr. Nelson’s insights on a weekly basis. The “ORS Connects” e-newsletter, a publication of the Orthopaedic Research Society, has kindly agreed to email OrthoBuzz readers Dr. Nelson’s weekly basic science tips. If you are interested, please email Amber Blake at blake@ors.org with your first and last name and email address.
Because Dr. Nelson’s tips are now available to a wider audience on a more frequent basis, we will no longer be including them in OrthoBuzz. The OrthoBuzz team has thoroughly enjoyed engaging with Dr. Nelson and his fascinating basic-science content. We thank him for his outstanding contributions.
Journal Club Resident Spotlight: Abdulaziz Ahmed
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: Abdulaziz Ahmed, MD
Affiliation: Hamad Medical Corp., Doha, Qatar
What was the topic of the most “dynamic” journal club meeting you have had so far this year?
One distinctive journal club evaluated two Level-I studies that addressed common sports-medicine procedures. One article was a randomized clinical trial (RCT) that evaluated the effectiveness of acromioplasty when added to full-thickness rotator cuff tear repair (Abrams GD, et al. Arthroscopic Repair of Full-Thickness Rotator Cuff Tears with and Without Acromioplasty: Randomized Prospective Trial With 2-Year Follow-up. Am J Sports Med. 2014 Jun;42[6]:1296-303). The second article was a trial that compared hip arthroscopy versus nonoperative treatment for femoroacetabular impingement (Griffin DR, et al. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome [UK FASHIoN]: a multicentre randomized controlled trial. Lancet. 2018 Jun 2;391[10136]:2225-2235). By completing systematic critical-appraisal forms, the residents were able to dissect and digest complex methodology and statistics. Both articles provided high-value learning points on evaluating the mechanics and limitations of randomized trials.
What are the top 3 characteristics of an engaging, enlightening journal club presentation?
First, audience preparedness is essential to an engaging journal club. Thus, articles should be distributed in advance for prereading. In our program, we circulate articles 4 weeks in advance. In addition, we highlight important educational objectives for each article. This allows residents to concentrate on crucial elements of selected articles, especially when analyzing several articles in one sitting. Second, selected articles have to be pertinent to the residents’ curriculum and clinical exposure. Our journal club articles are hand-picked jointly by senior residents and research-oriented faculty. The senior residents ensure the article’s relevance to residents, while experienced faculty provide oversight and refine article selection. Third, a systematic approach maximizes the beneficial value of the journal club. We provide participants with a systematic critical-appraisal checklist that not only enhances the residents’ critical appraisal, but also helps them adopt efficient lifelong reading tactics.
Aside from orthopaedic content, what have you been reading lately?
I have been reading the book Deep Work by Cal Newport. The book teaches valuable strategies for optimizing productivity and getting the most out of our cognitive abilities—a much-needed skill in our currently fast-paced, distracted world.
How has the COVID-19 pandemic affected your journal-club activities?
The COVID-19 pandemic has profoundly affected residency training around the globe. Although the pandemic limited our in-person journal club format, like many others, we have transitioned to virtual education. Currently, our journal club is conducted through online meetings. As much as we loved the in-person format, the online format made the journal club more accessible to faculty members. Moreover, the virtual setting motivated us to invite experts in the field. Recently, Dr. Bashir Zikria from Johns Hopkins moderated an exciting journal club on the long-term outcomes of matrix-induced autologous chondrocyte implantation.
How has free access to JBJS Clinical Classroom benefited you and your journal club?
JBJS Clinical Classroom has been a useful source for article selection in our journal club. It also provides an exciting opportunity to evaluate our knowledge by strengthening deficient areas and steering us away from mastered topics. The recharge feature provides a time-efficient way to reinforce knowledge. Clinical Classroom presents questions that are based on the best available evidence, and cited references feature both classic and most recent articles.
Making History Together
JBJS announces its new, interactive website, Making History Together, which celebrates 130 years of history at JBJS and the collective history of the field of orthopaedic surgery. The focal point of the new site is a dynamic timeline highlighting key moments and people in orthopaedics from 1887 to the present.
“We designed this site to give you a glimpse into our shared, collective past and show you how JBJS and the field of orthopaedic surgery have evolved over the last century-plus,” says JBJS Editor-in-Chief Marc Swiontkowski, MD. “The site is both informative and entertaining, and we hope that it helps you to feel more closely connected to those who paved the way for current and future orthopaedic surgeons.”
Browse the Making History Together timeline here.
Watch the introductory video:
The Making History Together site also spotlights:
- The people responsible for leading and producing JBJS, including our Editors-in-Chief, journal editors, reviewers, board of directors, and staff members
- JBJS products, including our flagship Journal of Bone & Joint Surgery, additional print and digital publications, podcasts, videos, and educational events and offerings
- Classic JBJS articles, including early and more recent practice-changing discoveries that were first described in our pages
- How the JBJS organization has grown in size and scope over the years, from a small, scholarly, printed journal to a multimedia content hub that meets the needs of a global, interconnected community of orthopaedic surgeons
JBJS is proud of its role in helping to advance the field of orthopaedic surgery over the last 130 years and is honored to be part of an orthopaedic community with a shared dedication and commitment to improving the musculoskeletal care of patients worldwide.
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.
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